Provider Demographics
NPI:1326537630
Name:THOMAS MAZURANIC DDS
Entity type:Organization
Organization Name:THOMAS MAZURANIC DDS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MAZURANIC
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:314-609-1660
Mailing Address - Street 1:17 E GLENWOOD LN
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-5118
Mailing Address - Country:US
Mailing Address - Phone:314-609-1660
Mailing Address - Fax:
Practice Address - Street 1:122 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:MO
Practice Address - Zip Code:63383-2004
Practice Address - Country:US
Practice Address - Phone:636-456-4746
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-02
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013016370261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1801236708OtherINDIVIDUAL NPI