Healthcare Provider Details

I. General information

NPI: 1467580001
Provider Name (Legal Business Name): MARK CARMODY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 MAIN ST
SUISUN CITY CA
94585-2401
US

IV. Provider business mailing address

807 MAIN ST
SUISUN CITY CA
94585-2401
US

V. Phone/Fax

Practice location:
  • Phone: 707-429-8611
  • Fax: 707-429-8686
Mailing address:
  • Phone: 707-429-8611
  • Fax: 707-429-8686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number23993
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: