Provider Demographics
NPI:1427038496
Name:FOGARTY, MARK EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:FOGARTY
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 1:256 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48111-2606
Mailing Address - Country:US
Mailing Address - Phone:734-697-9200
Mailing Address - Fax:734-697-9293
Practice Address - Street 1:256 3RD ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48111-2606
Practice Address - Country:US
Practice Address - Phone:734-697-9200
Practice Address - Fax:734-697-9293
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010127891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI352173422OtherEMPLOYER ID NUMBER