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General NPI Number Information
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NPI Number | 1467425546
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Entity Type | Individual
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Provider Name | MARK ARTHUR DETTELBACH M.D.
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Gender | Male
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Dates
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Enumeration Date | 02/09/2006
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Last Update Date | 06/26/2025
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Provider Practice Location Address
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Address Line | 5454 WISCONSIN AVE SUITE 1535
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City | CHEVY CHASE
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State | MD
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Zip | 20815-6901
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Country | US
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Telephone | 301-652-8847
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Fax | 301-652-8320
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Provider Business Mailing Address
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Address Line | 6201 GREENLEIGH AVE
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City | MIDDLE RIVER
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State | MD
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Zip | 21220-2004
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Country | US
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Telephone | 410-933-2704
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Fax | 410-500-4266
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | D47278
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 207YX0007X
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Taxonomy Name | Plastic Surgery within the Head & Neck (Otolaryngology) Physician
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License Number | MD21258
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License Number State | DC
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