Healthcare Provider Details

I. General information

NPI: 1912904640
Provider Name (Legal Business Name): MICHAEL MARK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

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

III. Provider practice location address

1 WASHINGTON SQ
NEW BRITAIN CT
06051-1848
US

IV. Provider business mailing address

635 MAIN ST
MIDDLETOWN CT
06457-2718
US

V. Phone/Fax

Practice location:
  • Phone: 860-224-3642
  • Fax: 860-826-5557
Mailing address:
  • Phone: 860-347-6971
  • Fax: 860-638-6601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number006957
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: