Healthcare Provider Details

I. General information

NPI: 1871883033
Provider Name (Legal Business Name): MARK DAVID MACEK DDS, DRPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2011
Last Update Date: 08/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 W BALTIMORE ST 2207
BALTIMORE MD
21201
US

IV. Provider business mailing address

650 W BALTIMORE ST 2207
BALTIMORE MD
21201-1510
US

V. Phone/Fax

Practice location:
  • Phone: 410-706-4218
  • Fax: 410-706-4031
Mailing address:
  • Phone: 410-706-4218
  • Fax: 410-706-4031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number15551
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019022453
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: