Healthcare Provider Details

I. General information

NPI: 1164491718
Provider Name (Legal Business Name): MARK TRACY DEAN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4886 SOCASTEE BLVD
MYRTLE BEACH SC
29588-7245
US

IV. Provider business mailing address

4886 SOCASTEE BLVD
MYRTLE BEACH SC
29588-7245
US

V. Phone/Fax

Practice location:
  • Phone: 843-293-1555
  • Fax:
Mailing address:
  • Phone: 843-293-1555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number679
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: