Provider Demographics
NPI:1902354772
Name:WARNER, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WARNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1175 HART AVE.
Mailing Address - Street 2:BRANCH DENTAL CLINIC YUMA
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85369
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2005 KNIGHT LANE BLDG H
Practice Address - Street 2:NAVY MEDICINE SUPPORT COMMAND ATTN: MEDICAL STAFF SVCS
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32212-0140
Practice Address - Country:US
Practice Address - Phone:760-725-3213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7136-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist