=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396298741
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON MARKS DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2016
-----------------------------------------------------
Last Update Date | 08/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5229 E TRINDLE RD
-----------------------------------------------------
City | MECHANICSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17050-3510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-697-4606
-----------------------------------------------------
Fax | 717-697-0573
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5229 E TRINDLE RD
-----------------------------------------------------
City | MECHANICSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17050-3510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-697-4606
-----------------------------------------------------
Fax | 717-697-0573
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DS041000
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------