Basic Information
| Provider Information | |||||||||
| NPI: | 1487269189 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STARCEVIC | ||||||||
| FirstName: | MIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1545 9TH ST SW | ||||||||
| Address2: | |||||||||
| City: | VERO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329624312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722578224 | ||||||||
| FaxNumber: | 7722133157 | ||||||||
| Practice Location | |||||||||
| Address1: | 12196 COUNTY ROAD 512 | ||||||||
| Address2: | |||||||||
| City: | FELLSMERE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329485463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722578224 | ||||||||
| FaxNumber: | 7722133157 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2020 | ||||||||
| LastUpdateDate: | 03/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DN25471 | FL | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | DN25471 | 01 | FL | STATE LICENSE | OTHER |