Healthcare Provider Details

I. General information

NPI: 1629191655
Provider Name (Legal Business Name): MARK CHRISTOPHER INTERIAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 TEJAS PL
NIPOMO CA
93444-9123
US

IV. Provider business mailing address

150 TEJAS PL PO BOX 430
NIPOMO CA
93444-9123
US

V. Phone/Fax

Practice location:
  • Phone: 805-929-3254
  • Fax: 805-929-6440
Mailing address:
  • Phone: 805-929-3254
  • Fax: 805-929-6440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number55333
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: