Healthcare Provider Details

I. General information

NPI: 1194255513
Provider Name (Legal Business Name): MARK ROBERT DUFFY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2017
Last Update Date: 10/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 W BROAD ST
COLUMBUS OH
43204-3783
US

IV. Provider business mailing address

2780 AIRPORT DR STE 100
COLUMBUS OH
43219-2289
US

V. Phone/Fax

Practice location:
  • Phone: 614-645-2300
  • Fax: 614-645-5517
Mailing address:
  • Phone: 614-859-1906
  • Fax: 614-645-5517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30.025112
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: