Provider Demographics
NPI:1235391103
Name:JOSEPHS, MARK R (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:JOSEPHS
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 1:16260 AIRLINE HWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-4272
Mailing Address - Country:US
Mailing Address - Phone:225-744-2660
Mailing Address - Fax:225-744-2666
Practice Address - Street 1:16260 AIRLINE HWY
Practice Address - Street 2:SUITE A
Practice Address - City:PRAIRIEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70769-4272
Practice Address - Country:US
Practice Address - Phone:225-744-2660
Practice Address - Fax:225-744-2666
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-01
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010197541223S0112X
LA6296122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1992051107OtherGROUP NPI