MEDICARE: DR. MARK BLAINE VINCENT D.D.S.

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	13287	TX

General Provider Information

NPI Number	:	1689636722
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK BLAINE VINCENT D.D.S.

Provider Business Mailing Address
First Line	:	3185 MERRIMAN ST
Second Line	:
City	:	PORT NECHES
State	:	TX
Zip	:	77651-6002
Country	:	US
Telephone Number	:	409-729-2303
Fax Number	:	409-729-2307

Provider Business Practice Location Address
First Line	:	3185 MERRIMAN ST
Second Line	:
City	:	PORT NECHES
State	:	TX
Zip	:	77651-6002
Country	:	US
Telephone Number	:	409-729-2303
Fax Number	:	409-729-2307

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

Provider Enumeration Date	:	04/04/2006
Last Update Date	:	03/02/2015

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