Provider Demographics
NPI:1043619463
Name:EASTMAN, MARK A (DDS,PC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:EASTMAN
Suffix:
Gender:M
Credentials:DDS,PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 FENTON RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-4034
Mailing Address - Country:US
Mailing Address - Phone:810-233-5361
Mailing Address - Fax:810-233-7952
Practice Address - Street 1:5301 FENTON RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-4034
Practice Address - Country:US
Practice Address - Phone:810-233-5361
Practice Address - Fax:810-233-7952
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI14252122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist