Provider Demographics
NPI:1194852608
Name:AZAR, MARK CHRISTOPHER (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:CHRISTOPHER
Last Name:AZAR
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3540 N BELT W
Mailing Address - Street 2:SUITE D
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5975
Mailing Address - Country:US
Mailing Address - Phone:618-235-3337
Mailing Address - Fax:618-235-8703
Practice Address - Street 1:3540 N BELT W
Practice Address - Street 2:SUITE D
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5975
Practice Address - Country:US
Practice Address - Phone:618-235-3337
Practice Address - Fax:618-235-8703
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19-A150991223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL19-A15099OtherSTATE SPECIALTY LICENSE