Provider Demographics
NPI:1215038732
Name:MAUTNER, MARK A (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:MAUTNER
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 1:197 POINT LOOKOUT DR
Mailing Address - Street 2:
Mailing Address - City:WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28697-7451
Mailing Address - Country:US
Mailing Address - Phone:954-309-7684
Mailing Address - Fax:
Practice Address - Street 1:197 POINT LOOKOUT DR
Practice Address - Street 2:
Practice Address - City:WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28697-7451
Practice Address - Country:US
Practice Address - Phone:954-309-7684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL94601223G0001X
NCNC110441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice