MEDICARE: DR. MARK FRANCIS ENVERGA DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	103004	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	103004	OTHER	CA	DENTAL BOARD OF CALIFORNIA

General Provider Information

NPI Number	:	1093293672
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK FRANCIS ENVERGA DDS

Provider Business Mailing Address
First Line	:	2508 S GROVE AVE
Second Line	:
City	:	ONTARIO
State	:	CA
Zip	:	91761-6253
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2508 S GROVE AVE
Second Line	:
City	:	ONTARIO
State	:	CA
Zip	:	91761-6253
Country	:	US
Telephone Number	:	909-635-5483
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2018
Last Update Date	:	08/05/2018

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