Provider Demographics
NPI:1205850377
Name:PETHICK, MARK (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:PETHICK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 LAYDON AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-2705
Mailing Address - Country:US
Mailing Address - Phone:203-234-7996
Mailing Address - Fax:
Practice Address - Street 1:532 CHAPEL ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-6905
Practice Address - Country:US
Practice Address - Phone:203-865-4286
Practice Address - Fax:203-865-2622
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT83111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice