Healthcare Provider Details

I. General information

NPI: 1093822470
Provider Name (Legal Business Name): JOHN E. MAZZA DDS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 04/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2480 MISSION ST SUITE #220
SAN FRANCISCO CA
94110-2468
US

IV. Provider business mailing address

2480 MISSION ST SUITE #220
SAN FRANCISCO CA
94110-2468
US

V. Phone/Fax

Practice location:
  • Phone: 415-641-5200
  • Fax: 415-641-7004
Mailing address:
  • Phone: 415-641-5200
  • Fax: 415-641-7004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number28758
License Number StateCA

VIII. Authorized Official

Name: DR. JOHN E MAZZA
Title or Position: PRESIDENT
Credential: DDS
Phone: 415-641-5200