1932753647 NPI number — DR. PATRICE LUZELLE ERMITA MARA DMD

Table of content: DR. PATRICE LUZELLE ERMITA MARA DMD (NPI 1932753647)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932753647 NPI number — DR. PATRICE LUZELLE ERMITA MARA DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARA
Provider First Name:
PATRICE
Provider Middle Name:
LUZELLE ERMITA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932753647
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/26/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
618TH DENTAL CO
Provider Second Line Business Mailing Address:
CARIUS DENTAL CLINIC BLDG P3020 ATTN: CREDENTIALS OFFIC
Provider Business Mailing Address City Name:
APO
Provider Business Mailing Address State Name:
AP
Provider Business Mailing Address Postal Code:
96271-5245
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
618TH DENTAL CO
Provider Second Line Business Practice Location Address:
CARIUS DENTAL CLINIC BLDG P3020 ATTN: CREDENTIALS OFFIC
Provider Business Practice Location Address City Name:
APO
Provider Business Practice Location Address State Name:
AP
Provider Business Practice Location Address Postal Code:
96271-5245
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-757-9186
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/31/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DEN.00204040 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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