MEDICARE: MAURICIO A MALO D.D.S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0700X	Prosthodontics	DN17046	FL

General Provider Information

NPI Number	:	1013119502
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAURICIO A MALO D.D.S

Provider Business Mailing Address
First Line	:	2525 EMBASSY DR STE 1
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33026-4573
Country	:	US
Telephone Number	:	954-430-3444
Fax Number	:	954-430-5688

Provider Business Practice Location Address
First Line	:	2525 EMBASSY DR STE 1
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33026-4573
Country	:	US
Telephone Number	:	954-430-3444
Fax Number	:	954-430-5688

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2007
Last Update Date	:	07/08/2007

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