Provider Demographics
NPI:1578652772
Name:EGBERT, MARK A (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:EGBERT
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 1:1959 NE PACIFIC ST
Mailing Address - Street 2:BOX 357131
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98195-7131
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1959 NE PACIFIC ST
Practice Address - Street 2:B241 HSB
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-7134
Practice Address - Country:US
Practice Address - Phone:206-543-7722
Practice Address - Fax:206-685-7222
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000055601223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery