Provider Demographics
NPI:1497968796
Name:PETERS, MARK PHILLIP (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:PHILLIP
Last Name:PETERS
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 1:2040 N. LOOP 336 W.
Mailing Address - Street 2:STE 207
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304
Mailing Address - Country:US
Mailing Address - Phone:936-539-7919
Mailing Address - Fax:936-756-2587
Practice Address - Street 1:2040 N LOOP 336 W
Practice Address - Street 2:STE 207
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-3500
Practice Address - Country:US
Practice Address - Phone:936-756-2420
Practice Address - Fax:936-756-2587
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX126861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice