Provider Demographics
NPI:1104028505
Name:GERGER, MARK ANTHONY (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:GERGER
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 1:2235 W ROSECRANS AVE
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90249-2905
Mailing Address - Country:US
Mailing Address - Phone:310-771-0990
Mailing Address - Fax:310-771-0991
Practice Address - Street 1:2235 W ROSECRANS AVE
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90249-2905
Practice Address - Country:US
Practice Address - Phone:310-771-0990
Practice Address - Fax:310-771-0991
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55310122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist