=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467739409
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER BURKE MAZZARELLA D.M.D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2011
-----------------------------------------------------
Last Update Date | 11/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17301 NW 27TH AVE
-----------------------------------------------------
City | MIAMI GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-624-1371
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 951 BRICKELL AVE APT 4111
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33131-3944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-793-7177
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | DN 18410
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------