Provider Demographics
NPI:1275563256
Name:FLETCHER, MARK C (MD, DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:FLETCHER
Suffix:
Gender:M
Credentials:MD, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 DALE RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3659
Mailing Address - Country:US
Mailing Address - Phone:860-674-8079
Mailing Address - Fax:860-676-8242
Practice Address - Street 1:34 DALE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3659
Practice Address - Country:US
Practice Address - Phone:860-674-8079
Practice Address - Fax:860-676-8242
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT87321223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTU82746Medicare UPIN