Healthcare Provider Details

I. General information

NPI: 1619989654
Provider Name (Legal Business Name): JOHN ROBERT MASCARO DMD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 01/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4230 STATE ROUTE 306 SUITE 350
WILLOUGHBY OH
44094
US

IV. Provider business mailing address

4230 STATE ROUTE 306 SUITE 350
WILLOUGHBY OH
44094
US

V. Phone/Fax

Practice location:
  • Phone: 440-946-2247
  • Fax: 440-946-3530
Mailing address:
  • Phone: 440-946-2247
  • Fax: 440-946-3530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number30019907
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number35066280
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: