Provider Demographics
NPI:1619058179
Name:MERCER, MARK CHARLES (LD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:CHARLES
Last Name:MERCER
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 S MARKET BLVD
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-3425
Mailing Address - Country:US
Mailing Address - Phone:360-740-7547
Mailing Address - Fax:360-740-7567
Practice Address - Street 1:1021 S MARKET BLVD
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-3425
Practice Address - Country:US
Practice Address - Phone:360-740-7547
Practice Address - Fax:360-740-7567
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN00000125122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist