Healthcare Provider Details

I. General information

NPI: 1275831133
Provider Name (Legal Business Name): MARK H HSU D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2011
Last Update Date: 10/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 W TAFT RD SUITE 3K
LIVERPOOL NY
13088-3807
US

IV. Provider business mailing address

5100 WEST TAFT RD, SUITE 3K NMC GENERAL DENTISTRY, PC
LIVERPOOL NY
13088
US

V. Phone/Fax

Practice location:
  • Phone: 315-452-2700
  • Fax: 315-452-2705
Mailing address:
  • Phone: 315-452-2700
  • Fax: 315-452-2705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number042499
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number24295
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: