Provider Demographics
NPI:1154468858
Name:EIDELMAN, MARK (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:EIDELMAN
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 1:300 MID RIVERS MALL DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-1565
Mailing Address - Country:US
Mailing Address - Phone:636-397-5883
Mailing Address - Fax:636-397-5887
Practice Address - Street 1:300 MID RIVERS MALL DR
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1565
Practice Address - Country:US
Practice Address - Phone:636-397-5883
Practice Address - Fax:636-397-5887
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO117851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice