Active NPI
Raymond J Mazuchowski Jr., DDS
- Dentist
- San Pedro, CA
National Provider Identifier
1255875944
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 1001463
- Practice address
- 697 S Gaffery St
San Pedro, CA 90731 - Phone
- (310) 925-3477
- NPI assigned
- Dec 14, 2016
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 1001463 | WI | Primary |
Addresses
Primary practice location
697 S Gaffery St
San Pedro, CA 90731
Mailing address
697 S Gaffey St
San Pedro, CA 90731-3026
Phone (310) 925-3477
Other practice location 1
1931 Main St
Green Bay, WI 54302-3920
Phone (888) 988-4066
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in WI
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20161220000003 | WI | Order and Referring Only - Dentist | 2365723996 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 1001463 | WI | MD | Dentist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Raymond Mazuchowski DDS | Current | Accepting new patients | |
| Familia Dental Green Bay East LLC | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Dental Clinic/Center
- Marinette, WI
- NPI 1518649920
-
dba Familia Dental
- Dental Clinic/Center
- Green Bay, WI
- NPI 1194188706
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1481673600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1595203200000",
"number": "1255875944",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "697 S GAFFEY ST",
"city": "SAN PEDRO",
"state": "CA",
"postal_code": "907313026",
"telephone_number": "310-925-3477"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "697 S GAFFERY ST",
"city": "SAN PEDRO",
"state": "CA",
"postal_code": "90731",
"telephone_number": "310-925-3477"
}
],
"practiceLocations": [
{
"address_1": "1931 Main St",
"address_purpose": "LOCATION",
"city": "Green Bay",
"state": "WI",
"postal_code": "543023920",
"country_code": "US",
"telephone_number": "888-988-4066",
"fax_number": "847-496-4850",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "MAZUCHOWSKI",
"first_name": "RAYMOND",
"middle_name": "J",
"name_suffix": "Jr.",
"credential": "DDS",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2016-12-14",
"last_updated": "2020-07-20",
"certification_date": "2020-07-20",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "WI",
"license": "1001463",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in San Pedro, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 20, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.