Healthcare Provider Details

I. General information

NPI: 1285941005
Provider Name (Legal Business Name): MARK A. GEORGE D.D.S., INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2010
Last Update Date: 09/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 W LA VETA AVE STE 530
ORANGE CA
92868-4227
US

IV. Provider business mailing address

1140 W LA VETA AVE STE 530
ORANGE CA
92868-4227
US

V. Phone/Fax

Practice location:
  • Phone: 714-953-1000
  • Fax: 714-953-9957
Mailing address:
  • Phone: 714-953-1000
  • Fax: 714-953-9957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number31142
License Number StateCA

VIII. Authorized Official

Name: MRS. DIANA LESLIE COSTELLO
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 714-953-1000