Provider Demographics
NPI:1417174582
Name:MOREAU, MARK (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MOREAU
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-1010
Mailing Address - Country:US
Mailing Address - Phone:518-584-6768
Mailing Address - Fax:518-584-6855
Practice Address - Street 1:200 CHURCH STREET
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866
Practice Address - Country:US
Practice Address - Phone:518-584-6768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0315891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice