Provider Demographics
NPI:1508228131
Name:GENCO, MARK (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:GENCO
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 1:418 SAINT MARKS PL
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-2434
Mailing Address - Country:US
Mailing Address - Phone:718-720-6836
Mailing Address - Fax:718-720-6996
Practice Address - Street 1:418 SAINT MARKS PL
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-2434
Practice Address - Country:US
Practice Address - Phone:718-720-6836
Practice Address - Fax:718-720-6996
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-23
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041072122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist