Provider Demographics
NPI:1407945280
Name:FUNT, MARK J (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:FUNT
Suffix:
Gender:M
Credentials:DMD
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Mailing Address - Street 1:401 TOWNSHIP LINE RD
Mailing Address - Street 2:STE C
Mailing Address - City:ELKINS PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027-2202
Mailing Address - Country:US
Mailing Address - Phone:215-379-5520
Mailing Address - Fax:215-663-5934
Practice Address - Street 1:401 TOWNSHIP LINE RD
Practice Address - Street 2:STE C
Practice Address - City:ELKINS PARK
Practice Address - State:PA
Practice Address - Zip Code:19027-2202
Practice Address - Country:US
Practice Address - Phone:215-379-5520
Practice Address - Fax:215-663-5934
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2008-05-23
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Provider Licenses
StateLicense IDTaxonomies
PADS019726L204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
T75670Medicare UPIN
PA049309Medicare PIN