Provider Demographics
NPI:1457687170
Name:DEWAELE, MARK STEVEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:STEVEN
Last Name:DEWAELE
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 1:208 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW CANAAN
Mailing Address - State:CT
Mailing Address - Zip Code:06840
Mailing Address - Country:US
Mailing Address - Phone:203-966-5944
Mailing Address - Fax:203-966-9154
Practice Address - Street 1:208 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:NEW CANAAN
Practice Address - State:CT
Practice Address - Zip Code:06840
Practice Address - Country:US
Practice Address - Phone:203-966-5944
Practice Address - Fax:203-966-9154
Is Sole Proprietor?:No
Enumeration Date:2009-10-30
Last Update Date:2009-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT66711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice