Healthcare Provider Details

I. General information

NPI: 1326028127
Provider Name (Legal Business Name): MARK EDWARD IOCCA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 SPRING ARBOR RD STE A
JACKSON MI
49203-2636
US

IV. Provider business mailing address

2000 SPRING ARBOR RD STE A
JACKSON MI
49203-2636
US

V. Phone/Fax

Practice location:
  • Phone: 517-787-5210
  • Fax: 517-787-9223
Mailing address:
  • Phone: 517-787-5210
  • Fax: 517-787-9223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10683
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: