Healthcare Provider Details

I. General information

NPI: 1336492024
Provider Name (Legal Business Name): DONNA MAHACEK RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2012
Last Update Date: 10/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2764 SEBASTIAN CT
JACKSONVILLE FL
32224-2896
US

IV. Provider business mailing address

2764 SEBASTIAN CT
JACKSONVILLE FL
32224-2896
US

V. Phone/Fax

Practice location:
  • Phone: 904-655-4259
  • Fax:
Mailing address:
  • Phone: 904-655-4259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDN21909
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: