Healthcare Provider Details

I. General information

NPI: 1740885664
Provider Name (Legal Business Name): MARIELA MULET GARCIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 11/30/2020
Certification Date: 11/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13401 SUMMERLIN RD STE 8
FORT MYERS FL
33919-6593
US

IV. Provider business mailing address

2560 KEYSTONE LAKE DR
CAPE CORAL FL
33909-2941
US

V. Phone/Fax

Practice location:
  • Phone: 239-415-1880
  • Fax: 239-415-1884
Mailing address:
  • Phone: 786-318-9523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH22317
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: