MEDICARE: DR. MARK WILLIAM SISKO DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	22D101282800	NJ

General Provider Information

NPI Number	:	1134112493
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK WILLIAM SISKO DDS

Provider Business Mailing Address
First Line	:	4311 LANDIS AVE
Second Line	:	P.O. BOX NO. 643
City	:	SEA ISLE CITY
State	:	NJ
Zip	:	08243-1838
Country	:	US
Telephone Number	:	609-263-4201
Fax Number	:	609-263-0433

Provider Business Practice Location Address
First Line	:	4311 LANDIS AVE
Second Line	:
City	:	SEA ISLE CITY
State	:	NJ
Zip	:	08243-1838
Country	:	US
Telephone Number	:	609-263-4201
Fax Number	:	609-263-0433

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2005
Last Update Date	:	07/08/2007

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