Healthcare Provider Details

I. General information

NPI: 1215002225
Provider Name (Legal Business Name): MARK I DEGEN D.D.S., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 05/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4730 S FORT APACHE RD STE 390
LAS VEGAS NV
89147-7945
US

IV. Provider business mailing address

4730 S FORT APACHE RD STE 390
LAS VEGAS NV
89147-7945
US

V. Phone/Fax

Practice location:
  • Phone: 702-253-9090
  • Fax: 702-253-9083
Mailing address:
  • Phone: 702-253-9090
  • Fax: 702-253-9083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number10535
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: