Healthcare Provider Details

I. General information

NPI: 1861823536
Provider Name (Legal Business Name): RICHARD MAUTNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2013
Last Update Date: 01/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 ARTHUR GODFREY RD STE 207
MIAMI BEACH FL
33140-3338
US

IV. Provider business mailing address

925 ARTHUR GODFREY RD SUITE #207
MIAMI BEACH FL
33140-3325
US

V. Phone/Fax

Practice location:
  • Phone: 305-531-0841
  • Fax: 305-531-2808
Mailing address:
  • Phone: 305-531-0841
  • Fax: 305-531-2808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number6909
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: