Provider Demographics
NPI:1114538253
Name:MARK K BATESOLE, DDS, MS, INC
Entity Type:Organization
Organization Name:MARK K BATESOLE, DDS, MS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:BATESOLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:805-628-2425
Mailing Address - Street 1:1055 BANGOR LN
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93001-3820
Mailing Address - Country:US
Mailing Address - Phone:949-374-6458
Mailing Address - Fax:
Practice Address - Street 1:178 S VICTORIA AVE STE C
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-4369
Practice Address - Country:US
Practice Address - Phone:805-628-2425
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty