Provider Demographics
NPI:1609815109
Name:GEORGE, MARK S (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:GEORGE
Suffix:
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 1:6 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641-3810
Mailing Address - Country:US
Mailing Address - Phone:802-476-4812
Mailing Address - Fax:802-476-0525
Practice Address - Street 1:6 NORTH ST
Practice Address - Street 2:1
Practice Address - City:BARRE
Practice Address - State:VT
Practice Address - Zip Code:05641-3810
Practice Address - Country:US
Practice Address - Phone:802-476-4812
Practice Address - Fax:802-475-0525
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT792122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1002191Medicaid