Provider Demographics
NPI:1285631135
Name:WIDLOSKI, MARK M (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:M
Last Name:WIDLOSKI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 E LAMAR ALEXANDER PKWY
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37804-5131
Mailing Address - Country:US
Mailing Address - Phone:865-983-8630
Mailing Address - Fax:865-983-3616
Practice Address - Street 1:1505 E LAMAR ALEXANDER PKWY
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5131
Practice Address - Country:US
Practice Address - Phone:865-983-8630
Practice Address - Fax:865-983-3616
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS47111223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3225440Medicaid
TN3225440Medicaid
TN3225440Medicare ID - Type Unspecified