Larisa Igorevna Macedo, DMD

Primary specialty

DentistTaxonomy code 122300000X

License

2021022228 Issued in MO

Practice address

26831 S Tamiami TRL Unit 48
Bonita Springs, FL 34134-7828

Phone

(239) 948-3200

NPI assigned

Jul 13, 2021

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other names 1

• Larisa Igorevna Mironova Former name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Networks

• Freedom Health HMO Network

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1626134400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1689379200000",
    "number": "1922670561",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2411 FRYER PT",
            "city": "FORT LAUDERDALE",
            "state": "FL",
            "postal_code": "333052722",
            "telephone_number": "312-826-9218"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "26831 S TAMIAMI TRL UNIT 48",
            "city": "BONITA SPRINGS",
            "state": "FL",
            "postal_code": "341347828",
            "telephone_number": "239-948-3200"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MACEDO",
        "first_name": "LARISA",
        "middle_name": "IGOREVNA",
        "name_prefix": "Dr.",
        "credential": "DMD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2021-07-13",
        "last_updated": "2023-07-15",
        "certification_date": "2023-07-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "MO",
            "license": "2021022228",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "LARISA",
            "last_name": "MIRONOVA",
            "middle_name": "IGOREVNA",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

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• Dentist in Bonita Springs, FL
• Providers in Bonita Springs, FL by specialty
• Dentist in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 15, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.