Provider Demographics
NPI:1548797541
Name:TINNEY, MARK CLIFFORD (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:CLIFFORD
Last Name:TINNEY
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 1:520 PHYLLIS DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-4222
Mailing Address - Country:US
Mailing Address - Phone:1504-228-5988
Mailing Address - Fax:
Practice Address - Street 1:9020 W JUDGE PEREZ DR
Practice Address - Street 2:
Practice Address - City:CHALMETTE
Practice Address - State:LA
Practice Address - Zip Code:70043-4500
Practice Address - Country:US
Practice Address - Phone:504-277-4401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA67571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice