Provider Demographics
NPI:1215002225
Name:DEGEN, MARK I (DDS, MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:I
Last Name:DEGEN
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4730 S FORT APACHE RD
Mailing Address - Street 2:STE 390
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-7945
Mailing Address - Country:US
Mailing Address - Phone:702-253-9090
Mailing Address - Fax:702-253-9083
Practice Address - Street 1:4730 S FORT APACHE RD
Practice Address - Street 2:STE 390
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147-7945
Practice Address - Country:US
Practice Address - Phone:702-253-9090
Practice Address - Fax:702-253-9083
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV105351223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1598946261OtherGROUP NPI NUMBER
NV200078388OtherTAX ID
NV38085Medicare PIN
NV200078388OtherTAX ID