MEDICARE: GREGORY MARK 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	046175	NY

General Provider Information

NPI Number	:	1891784153
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY MARK DDS

Provider Business Mailing Address
First Line	:	6761 110TH ST
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-2943
Country	:	US
Telephone Number	:	718-268-0458
Fax Number	:

Provider Business Practice Location Address
First Line	:	6509 99TH ST
Second Line	:	SUITE D
City	:	REGO PARK
State	:	NY
Zip	:	11374-3570
Country	:	US
Telephone Number	:	718-275-9792
Fax Number	:	718-997-8362

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

Provider Enumeration Date	:	10/19/2005
Last Update Date	:	07/08/2007

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