Provider Demographics
NPI:1861542169
Name:DEFONTE, MARK (DMD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:DEFONTE
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 1:59 BEAVERBROOK RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LINCOLN PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07035-1794
Mailing Address - Country:US
Mailing Address - Phone:973-686-0060
Mailing Address - Fax:973-686-0770
Practice Address - Street 1:59 BEAVERBROOK RD
Practice Address - Street 2:SUITE 301
Practice Address - City:LINCOLN PARK
Practice Address - State:NJ
Practice Address - Zip Code:07035-1794
Practice Address - Country:US
Practice Address - Phone:973-686-0060
Practice Address - Fax:973-686-0770
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ179181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice