Provider Demographics
NPI:1629287255
Name:MARK A. EBY D.D.S., P.C.
Entity Type:Organization
Organization Name:MARK A. EBY D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:EBY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:734-243-5200
Mailing Address - Street 1:15555 S TELEGRAPH RD
Mailing Address - Street 2:SUITE 7
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-4000
Mailing Address - Country:US
Mailing Address - Phone:734-243-5200
Mailing Address - Fax:734-241-6127
Practice Address - Street 1:15555 S TELEGRAPH RD
Practice Address - Street 2:SUITE 7
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-4000
Practice Address - Country:US
Practice Address - Phone:734-243-5200
Practice Address - Fax:734-241-6127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010181991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty