Provider Demographics
NPI:1699941492
Name:GOTTFRIED, MARINA MAZIANITOU (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:MARINA
Middle Name:MAZIANITOU
Last Name:GOTTFRIED
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-3124
Mailing Address - Country:US
Mailing Address - Phone:718-267-0641
Mailing Address - Fax:
Practice Address - Street 1:2615 23RD AVE
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-3124
Practice Address - Country:US
Practice Address - Phone:718-267-0641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041176-11223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01574510Medicaid