Provider Demographics
NPI:1073733606
Name:MAZURKIEWICZ, MARK R (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:MAZURKIEWICZ
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 1:1025 FOOTE ST
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-4911
Mailing Address - Country:US
Mailing Address - Phone:662-287-3156
Mailing Address - Fax:662-287-3157
Practice Address - Street 1:1025 FOOTE ST
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-4911
Practice Address - Country:US
Practice Address - Phone:662-287-3156
Practice Address - Fax:662-287-3157
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3407-071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice