Basic Information
| Provider Information | |||||||||
| NPI: | 1245333756 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEMARCO | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DEMARCO DDS INC | ||||||||
| OtherFirstName: | JOHN | ||||||||
| OtherMiddleName: | M. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DDS | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1357 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339021357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402964965 | ||||||||
| FaxNumber: | 2392783857 | ||||||||
| Practice Location | |||||||||
| Address1: | 4300 KINGS HWY | ||||||||
| Address2: | #500 | ||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339802917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393442337 | ||||||||
| FaxNumber: | 9416292365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2006 | ||||||||
| LastUpdateDate: | 03/26/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 30014059 | OH | N | Dental Providers | Dentist | General Practice | 1223G0001X | HAD46 | FL | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 005587200 | 05 | FL | MEDICAID | 0248637 | 05 | OH | MEDICAID |