Provider Demographics
NPI:1568428753
Name:MARK E. POTOCKI DDS, PC
Entity Type:Organization
Organization Name:MARK E. POTOCKI DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:POTOCKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:517-625-4163
Mailing Address - Street 1:PO BOX 619
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:MI
Mailing Address - Zip Code:48872-0619
Mailing Address - Country:US
Mailing Address - Phone:517-625-4163
Mailing Address - Fax:517-625-5049
Practice Address - Street 1:114 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:MI
Practice Address - Zip Code:48872-0619
Practice Address - Country:US
Practice Address - Phone:517-625-4163
Practice Address - Fax:517-625-5049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2009-09-29
Deactivation Date:2006-07-18
Deactivation Code:
Reactivation Date:2009-09-29
Provider Licenses
StateLicense IDTaxonomies
MI0144561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1957815500Medicare UPIN