MEDICARE: MARIO MAMDOUH TOMA DMD

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	122300000X	Dentist	30292	FL

General Provider Information

NPI Number	:	1508753773
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIO MAMDOUH TOMA DMD

Provider Business Mailing Address
First Line	:	5315 CORDGRASS BEND LN
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32128-3000
Country	:	US
Telephone Number	:	386-316-4217
Fax Number	:

Provider Business Practice Location Address
First Line	:	4904 CLYDE MORRIS BLVD
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32129-4170
Country	:	US
Telephone Number	:	386-202-1278
Fax Number	:

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

Provider Enumeration Date	:	06/20/2025
Last Update Date	:	07/01/2025

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