Healthcare Provider Details

I. General information

NPI: 1831174556
Provider Name (Legal Business Name): DR. MARK A DUCKETT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

Provider Other Name: MARK A DUCKETT DDS

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 ARNOLD AVE VA /MCCLELLAN DENTAL SERVICE
SCRAMENTO CA
95652
US

IV. Provider business mailing address

8300 AUBURN FOLSOM RD
GRANITE BAY CA
95746-9381
US

V. Phone/Fax

Practice location:
  • Phone: 916-561-7800
  • Fax:
Mailing address:
  • Phone: 916-561-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number43780
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: