Provider Demographics
NPI:1326135880
Name:BRAITHWAITE, MARK WINSTON (DDS, MA)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:WINSTON
Last Name:BRAITHWAITE
Suffix:
Gender:M
Credentials:DDS, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:159 MIDWOOD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-5060
Mailing Address - Country:US
Mailing Address - Phone:718-287-6756
Mailing Address - Fax:
Practice Address - Street 1:950 CAMPBELL AVE
Practice Address - Street 2:VA CONNECTICUT HEALTHCARE SYSTEM, DENTAL SERVICE 160
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-2770
Practice Address - Country:US
Practice Address - Phone:203-932-5711
Practice Address - Fax:203-937-4895
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190244871223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics