Provider Demographics
NPI:1144423666
Name:MARCUS, MARK CHARLES (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:CHARLES
Last Name:MARCUS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13320 RIVERSIDE DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-2502
Mailing Address - Country:US
Mailing Address - Phone:818-789-8892
Mailing Address - Fax:818-789-2916
Practice Address - Street 1:13320 RIVERSIDE DR
Practice Address - Street 2:SUITE 204
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-2502
Practice Address - Country:US
Practice Address - Phone:818-789-8892
Practice Address - Fax:818-789-2916
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA297451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice