Provider Demographics
NPI:1528529765
Name:ANDA CONZA, MAURICIO XAVIER (DMD)
Entity type:Individual
Prefix:DR
First Name:MAURICIO
Middle Name:XAVIER
Last Name:ANDA CONZA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6805 PORTO FINO CIR BLDG C
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4353
Mailing Address - Country:US
Mailing Address - Phone:786-838-3659
Mailing Address - Fax:
Practice Address - Street 1:6805 PORTO FINO CIR BLDG C
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4353
Practice Address - Country:US
Practice Address - Phone:239-482-8806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-29
Last Update Date:2024-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH30.0261331223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223G0001XDental ProvidersDentistGeneral Practice