Healthcare Provider Details

I. General information

NPI: 1467471946
Provider Name (Legal Business Name): MARK ALAN MIZNER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

388 COMMONWEALTH AVE
BOSTON MA
02215-2800
US

IV. Provider business mailing address

388 COMMONWEALTH AVE
BOSTON MA
02215-2800
US

V. Phone/Fax

Practice location:
  • Phone: 616-266-8770
  • Fax: 617-266-9530
Mailing address:
  • Phone: 616-266-8770
  • Fax: 617-266-9530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14475
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: