Provider Demographics
NPI:1780615476
Name:CASTOR, MARK G (DMD, PA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:G
Last Name:CASTOR
Suffix:
Gender:M
Credentials:DMD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 PRESTON EXECUTIVE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-8488
Mailing Address - Country:US
Mailing Address - Phone:919-467-6111
Mailing Address - Fax:919-380-0088
Practice Address - Street 1:140 PRESTON EXECUTIVE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27513-8488
Practice Address - Country:US
Practice Address - Phone:919-467-6111
Practice Address - Fax:919-380-0088
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC61031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8991437Medicaid