Provider Demographics
NPI:1780412072
Name:PEZZULLA, MAURA KATHLEEN (DMD)
Entity type:Individual
Prefix:
First Name:MAURA
Middle Name:KATHLEEN
Last Name:PEZZULLA
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 1:1373 OLIVER AVE APT B
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-5164
Mailing Address - Country:US
Mailing Address - Phone:443-834-9148
Mailing Address - Fax:
Practice Address - Street 1:2841 RENDOVA RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92155-1098
Practice Address - Country:US
Practice Address - Phone:760-214-6978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-26
Last Update Date:2025-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14015702-9926122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist