Provider Demographics
NPI:1962473793
Name:MAUCK, MICHAEL GLENN (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GLENN
Last Name:MAUCK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1051 S STATE ROAD 7 # 441
Mailing Address - Street 2:BLDG. G, SUITE #1
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-6135
Mailing Address - Country:US
Mailing Address - Phone:561-790-0206
Mailing Address - Fax:561-795-5445
Practice Address - Street 1:1051 S STATE ROAD 7 # 441
Practice Address - Street 2:BLDG. G, SUITE #1
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-6135
Practice Address - Country:US
Practice Address - Phone:561-790-0206
Practice Address - Fax:561-795-5445
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN98811223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT94379Medicare UPIN
FL67369Medicare ID - Type Unspecified