Healthcare Provider Details

I. General information

NPI: 1316265358
Provider Name (Legal Business Name): MARK RICHARDS DURHAM D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2010
Last Update Date: 05/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4946 YORK ST
METAIRIE LA
70001-1036
US

IV. Provider business mailing address

4946 YORK ST
METAIRIE LA
70001-1036
US

V. Phone/Fax

Practice location:
  • Phone: 504-324-4309
  • Fax:
Mailing address:
  • Phone: 504-324-4309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberS-492
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: