Provider Demographics
NPI:1578774071
Name:CERRACHIO, MARK STEVEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:STEVEN
Last Name:CERRACHIO
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 1:26 JOSEPH LN
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-2825
Mailing Address - Country:US
Mailing Address - Phone:718-981-2123
Mailing Address - Fax:
Practice Address - Street 1:774 CARROLL ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-1403
Practice Address - Country:US
Practice Address - Phone:718-622-7231
Practice Address - Fax:718-622-7224
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY345021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice