Provider Demographics
NPI:1174213607
Name:MERAYO GODO, MARIAM (DMD)
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:MERAYO GODO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11810 THICKET WOOD DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-4306
Mailing Address - Country:US
Mailing Address - Phone:502-533-1821
Mailing Address - Fax:
Practice Address - Street 1:4921 STATE ROAD 674
Practice Address - Street 2:
Practice Address - City:WIMAUMA
Practice Address - State:FL
Practice Address - Zip Code:33598-3534
Practice Address - Country:US
Practice Address - Phone:813-819-3254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-09
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10953122300000X
FLDN28735122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist