Healthcare Provider Details

I. General information

NPI: 1962473793
Provider Name (Legal Business Name): MICHAEL GLENN MAUCK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 12/21/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 S STATE ROAD 7 # 441 BLDG. G, SUITE #1
WELLINGTON FL
33414-6135
US

IV. Provider business mailing address

1051 S STATE ROAD 7 # 441 BLDG. G, SUITE #1
WELLINGTON FL
33414-6135
US

V. Phone/Fax

Practice location:
  • Phone: 561-790-0206
  • Fax: 561-795-5445
Mailing address:
  • Phone: 561-790-0206
  • Fax: 561-795-5445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN9881
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: