Provider Demographics
NPI:1063876399
Name:ANTEZANA, MAURICIO
Entity type:Individual
Prefix:
First Name:MAURICIO
Middle Name:
Last Name:ANTEZANA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12188 SAG HARBOR CT APT 5
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-5529
Mailing Address - Country:US
Mailing Address - Phone:561-289-9112
Mailing Address - Fax:
Practice Address - Street 1:115 JOHN F KENNEDY DR
Practice Address - Street 2:
Practice Address - City:ATLANTIS
Practice Address - State:FL
Practice Address - Zip Code:33462-1152
Practice Address - Country:US
Practice Address - Phone:561-967-3513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
FLDN22246122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program