Provider Demographics
NPI:1528035946
Name:MEYER, MARK LAWRENCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LAWRENCE
Last Name:MEYER
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 1:1544 N PEACE HAVEN RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-1328
Mailing Address - Country:US
Mailing Address - Phone:336-768-1332
Mailing Address - Fax:336-768-9470
Practice Address - Street 1:1544 N PEACE HAVEN RD
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-1328
Practice Address - Country:US
Practice Address - Phone:336-768-1332
Practice Address - Fax:336-768-9470
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC55151223P0221X
VA67981223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC899590CMedicaid