Healthcare Provider Details

I. General information

NPI: 1912608043
Provider Name (Legal Business Name): MARIOLI LUCIANO DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2023
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13063 CORTEZ BLVD
BROOKSVILLE FL
34613-4838
US

IV. Provider business mailing address

12253 MATISSE CIR UNIT 308
NEW PORT RICHEY FL
34655-4758
US

V. Phone/Fax

Practice location:
  • Phone: 352-666-1400
  • Fax:
Mailing address:
  • Phone: 787-232-8046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN29450
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number29450
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: