Healthcare Provider Details

I. General information

NPI: 1790138774
Provider Name (Legal Business Name): MITCHELL GRUZMARK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2016
Last Update Date: 12/20/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4410 W 16TH AVE STE 52
HIALEAH FL
33012-7193
US

IV. Provider business mailing address

7225 PORT MARNOCK DR
HIALEAH FL
33015-2061
US

V. Phone/Fax

Practice location:
  • Phone: 305-825-9899
  • Fax:
Mailing address:
  • Phone: 847-757-8033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019030822
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN24566
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: