Provider Demographics
NPI:1598496440
Name:PUGLIESE, MARK GIRARD II (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:GIRARD
Last Name:PUGLIESE
Suffix:II
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 OCEAN AVE APT 103
Mailing Address - Street 2:
Mailing Address - City:OLD ORCHARD BEACH
Mailing Address - State:ME
Mailing Address - Zip Code:04064-2766
Mailing Address - Country:US
Mailing Address - Phone:717-517-6349
Mailing Address - Fax:
Practice Address - Street 1:171 MAINE MALL RD
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2310
Practice Address - Country:US
Practice Address - Phone:207-775-1551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-21
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MEDEN4996122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program