Provider Demographics
NPI:1144353988
Name:MARK, MARVIN R (DMD)
Entity type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:R
Last Name:MARK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10301 GEORGIA AVE
Mailing Address - Street 2:STE 307
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20902-5020
Mailing Address - Country:US
Mailing Address - Phone:301-593-4200
Mailing Address - Fax:301-754-1614
Practice Address - Street 1:10301 GEORGIA AVE
Practice Address - Street 2:STE 307
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20902-5020
Practice Address - Country:US
Practice Address - Phone:301-593-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD96321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDMA697948Medicare UPIN