Provider Demographics
NPI:1013983626
Name:PELLETIER, MARK G (DDS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:G
Last Name:PELLETIER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1181
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-1181
Mailing Address - Country:US
Mailing Address - Phone:803-781-7901
Mailing Address - Fax:803-749-1376
Practice Address - Street 1:900 LAKE MURRAY BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-2923
Practice Address - Country:US
Practice Address - Phone:803-781-7901
Practice Address - Fax:803-749-1376
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC32321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice