Healthcare Provider Details

I. General information

NPI: 1063609824
Provider Name (Legal Business Name): JULIA MAYZENBERG DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2007
Last Update Date: 09/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 GEIGER RD
PHILADELPHIA PA
19115-1008
US

IV. Provider business mailing address

240 GEIGER RD
PHILADELPHIA PA
19115-1008
US

V. Phone/Fax

Practice location:
  • Phone: 215-464-2411
  • Fax: 215-969-0215
Mailing address:
  • Phone: 215-464-2411
  • Fax: 215-969-0215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDS035665
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: