Healthcare Provider Details

I. General information

NPI: 1073770467
Provider Name (Legal Business Name): DR. MARK POTHITAKIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2008
Last Update Date: 05/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 E TOOTHACHE DR
NEW LONDON IA
52645-1141
US

IV. Provider business mailing address

107 E TOOTHACHE DR
NEW LONDON IA
52645-1141
US

V. Phone/Fax

Practice location:
  • Phone: 319-367-2311
  • Fax:
Mailing address:
  • Phone: 319-367-2311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7584
License Number StateIA

VIII. Authorized Official

Name: DR. MARK CHRIST POTHITAKIS
Title or Position: OWNER
Credential: D.D.S.
Phone: 319-367-2311