Provider Demographics
NPI:1386137370
Name:MAZA, ILKA (DDS)
Entity type:Individual
Prefix:DR
First Name:ILKA
Middle Name:
Last Name:MAZA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:ILKA
Other - Middle Name:
Other - Last Name:MAZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1530 TEXAS AVE S STE 300
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77840-3390
Mailing Address - Country:US
Mailing Address - Phone:832-883-9638
Mailing Address - Fax:
Practice Address - Street 1:1530 TEXAS AVE S STE 300
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77840-3390
Practice Address - Country:US
Practice Address - Phone:979-421-4093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-13
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX341711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice