Provider Demographics
NPI:1659305241
Name:DAILEY, MARK NOLAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:NOLAN
Last Name:DAILEY
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 1:2260 DORCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER CENTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-5620
Mailing Address - Country:US
Mailing Address - Phone:617-298-0104
Mailing Address - Fax:617-298-0104
Practice Address - Street 1:2260 DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER CENTER
Practice Address - State:MA
Practice Address - Zip Code:02124-5620
Practice Address - Country:US
Practice Address - Phone:617-298-0104
Practice Address - Fax:617-298-0104
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA118601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0222461Medicaid