Provider Demographics
NPI:1528324449
Name:ZGURI, MARITA (DMD)
Entity type:Individual
Prefix:
First Name:MARITA
Middle Name:
Last Name:ZGURI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375TH MEDICAL GROUP
Mailing Address - Street 2:310 LOSEY STREET
Mailing Address - City:SCOTT AFB
Mailing Address - State:IL
Mailing Address - Zip Code:62225
Mailing Address - Country:US
Mailing Address - Phone:617-816-9371
Mailing Address - Fax:
Practice Address - Street 1:3458 NEELY RD
Practice Address - Street 2:
Practice Address - City:JB MDL
Practice Address - State:NJ
Practice Address - Zip Code:08641
Practice Address - Country:US
Practice Address - Phone:617-816-9371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-04
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27793122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist