Provider Demographics
NPI:1558645648
Name:MAR, REGINA (DDS)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:MAR
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 E HOSPITAL RD
Mailing Address - Street 2:FORT GORDON DENTAC
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-6011
Mailing Address - Country:US
Mailing Address - Phone:706-787-5102
Mailing Address - Fax:
Practice Address - Street 1:228 E HOSPITAL RD
Practice Address - Street 2:FORT GORDON DENTAC
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905-6011
Practice Address - Country:US
Practice Address - Phone:706-787-5102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-06
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 60245431122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist