Provider Demographics
NPI:1912608043
Name:LUCIANO, MARIOLI (DMD)
Entity type:Individual
Prefix:DR
First Name:MARIOLI
Middle Name:
Last Name:LUCIANO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:361 CALLE GALILEO APT 2K
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00927-4511
Mailing Address - Country:US
Mailing Address - Phone:787-232-8046
Mailing Address - Fax:
Practice Address - Street 1:2800 UNIVERSITY BLVD N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-3394
Practice Address - Country:US
Practice Address - Phone:904-256-7846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-15
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN29450122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program