Provider Demographics
NPI:1003022195
Name:GILBERT, MARK SCOTT (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:SCOTT
Last Name:GILBERT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:
Other - Last Name:GILBERT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:924 AVENUE O
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230
Mailing Address - Country:US
Mailing Address - Phone:718-376-0022
Mailing Address - Fax:
Practice Address - Street 1:924 AVENUE O
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230
Practice Address - Country:US
Practice Address - Phone:718-376-0022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3472311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00682637Medicaid