Provider Demographics
NPI:1487862694
Name:DODDS, MARK JOSEPH (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JOSEPH
Last Name:DODDS
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 1:6828 CADWELL CIR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-9429
Mailing Address - Country:US
Mailing Address - Phone:317-414-6758
Mailing Address - Fax:
Practice Address - Street 1:150 N INDIANA ST
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46158-1506
Practice Address - Country:US
Practice Address - Phone:317-831-4240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-19
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120099931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200209760Medicaid