Healthcare Provider Details

I. General information

NPI: 1366547887
Provider Name (Legal Business Name): MARK P SAKAMAKI D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 PAOLI PIKE SUITE 202
FLOYDS KNOBS IN
47119-9695
US

IV. Provider business mailing address

4801 PAOLI PIKE SUITE 202
FLOYDS KNOBS IN
47119-9695
US

V. Phone/Fax

Practice location:
  • Phone: 812-923-1500
  • Fax: 812-923-7706
Mailing address:
  • Phone: 812-923-1500
  • Fax: 812-923-7706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number12011074A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8351
License Number StateKY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: