Provider Demographics
NPI:1184682585
Name:MCINNIS, MARK LANGLEY (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LANGLEY
Last Name:MCINNIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:201 FRONTAGE RD
Mailing Address - Street 2:STE 1
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29631
Mailing Address - Country:US
Mailing Address - Phone:864-654-7534
Mailing Address - Fax:864-654-4830
Practice Address - Street 1:201 FRONTAGE RD
Practice Address - Street 2:STE 1
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29631
Practice Address - Country:US
Practice Address - Phone:864-654-7534
Practice Address - Fax:864-654-4830
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3514 SPEC 05041223X0400X
SC05041223X0400X
SC3514122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics