Healthcare Provider Details

I. General information

NPI: 1669510285
Provider Name (Legal Business Name): MILLARD MAZER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10630 LITTLE PATUXENT PKWY
COLUMBIA MD
21044-3264
US

IV. Provider business mailing address

10630 LITTLE PATUXENT PKWY
COLUMBIA MD
21044-3264
US

V. Phone/Fax

Practice location:
  • Phone: 410-884-1179
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number9817
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: