Provider Demographics
NPI:1407866841
Name:ST MARKS DENTAL PC
Entity Type:Organization
Organization Name:ST MARKS DENTAL PC
Other - Org Name:ST MARKS DENTAL OFFICE
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:SALVATORE
Authorized Official - Last Name:GENCO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:718-720-6836
Mailing Address - Street 1:418 ST MARK'S PLACE
Mailing Address - Street 2:ST MARK'S DENTAL
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301
Mailing Address - Country:US
Mailing Address - Phone:718-720-6836
Mailing Address - Fax:718-720-6996
Practice Address - Street 1:418 ST MARK'S PLACE
Practice Address - Street 2:ST MARK'S DENTAL
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301
Practice Address - Country:US
Practice Address - Phone:718-720-6836
Practice Address - Fax:718-720-6996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041072122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01103644Medicaid