Healthcare Provider Details

I. General information

NPI: 1992729628
Provider Name (Legal Business Name): ANDREI MARK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 W 57TH ST SUITE#1004
NEW YORK NY
10019-2802
US

IV. Provider business mailing address

57 W 57TH ST SUITE#1004
NEW YORK NY
10019-2802
US

V. Phone/Fax

Practice location:
  • Phone: 212-813-0707
  • Fax: 212-813-0808
Mailing address:
  • Phone: 212-813-0707
  • Fax: 212-813-0808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number041022
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number041022
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number041022
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: