Healthcare Provider Details

I. General information

NPI: 1962591644
Provider Name (Legal Business Name): MARK J REDD D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25261 PASEO DE VALENCIA
LAGUNA HILLS CA
92637-4966
US

IV. Provider business mailing address

25261 PASEO DE VALENCIA
LAGUNA HILLS CA
92637-4966
US

V. Phone/Fax

Practice location:
  • Phone: 949-581-6641
  • Fax: 949-581-2831
Mailing address:
  • Phone: 949-581-6641
  • Fax: 949-581-2831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number44438
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: