Provider Demographics
NPI:1073697256
Name:HERMELIN, MARK JAY (DDS PC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JAY
Last Name:HERMELIN
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 1:337 EDWIN DRIVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462
Mailing Address - Country:US
Mailing Address - Phone:757-497-4746
Mailing Address - Fax:757-497-3698
Practice Address - Street 1:337 EDWIN DRIVE
Practice Address - Street 2:SUITE 101
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462
Practice Address - Country:US
Practice Address - Phone:757-497-4746
Practice Address - Fax:757-497-3698
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010056311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice