Provider Demographics
NPI:1629137708
Name:AVETOOM, MARK (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:AVETOOM
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 1:210 W. MAIN ST.
Mailing Address - Street 2:SUITE 106
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780
Mailing Address - Country:US
Mailing Address - Phone:714-544-1877
Mailing Address - Fax:714-832-3200
Practice Address - Street 1:210 W. MAIN ST.
Practice Address - Street 2:SUITE 106
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780
Practice Address - Country:US
Practice Address - Phone:714-544-1877
Practice Address - Fax:714-832-3200
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA361311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice