Provider Demographics
NPI:1639186919
Name:SMALL, MARK P (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:P
Last Name:SMALL
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 1:1090 NEW LONDON AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-3035
Mailing Address - Country:US
Mailing Address - Phone:401-738-2500
Mailing Address - Fax:401-463-6898
Practice Address - Street 1:1090 NEW LONDON AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-3035
Practice Address - Country:US
Practice Address - Phone:401-738-2500
Practice Address - Fax:401-463-6898
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI24421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice