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General NPI Number Information
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NPI Number | 1699985176
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Entity Type | Individual
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Provider Name | DR. MARK L. CIVIN
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Gender | Male
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Dates
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Enumeration Date | 05/23/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 5600 PGA BLVD SUITE 102A
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City | PALM BEACH GARDENS
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State | FL
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Zip | 33418-3900
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Country | US
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Telephone | 561-624-2224
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Fax |
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Provider Business Mailing Address
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Address Line | 5600 P.G.A. BLVD SUITE 102 A
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City | PALM BEACH GARDENS
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State | FL
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Zip | 33418
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Country | US
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Telephone | 772-545-9292
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Fax |
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 8487
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License Number State | FL
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