Healthcare Provider Details

I. General information

NPI: 1467425546
Provider Name (Legal Business Name): MARK ARTHUR DETTELBACH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5454 WISCONSIN AVE SUITE 1535
CHEVY CHASE MD
20815-6901
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
MIDDLE RIVER MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 301-652-8847
  • Fax: 301-652-8320
Mailing address:
  • Phone: 410-933-2704
  • Fax: 410-500-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberD47278
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License NumberMD21258
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: