Provider Demographics
NPI:1659390862
Name:ST MARK DENTAL PC
Entity Type:Organization
Organization Name:ST MARK DENTAL PC
Other - Org Name:FAMILY DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EVEBAKHIT
Authorized Official - Middle Name:TADROS
Authorized Official - Last Name:BAKHIT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:508-533-7890
Mailing Address - Street 1:113 MAIN ST
Mailing Address - Street 2:NONE
Mailing Address - City:MEDWAY
Mailing Address - State:MA
Mailing Address - Zip Code:02053-1802
Mailing Address - Country:US
Mailing Address - Phone:508-533-7890
Mailing Address - Fax:508-533-7890
Practice Address - Street 1:113 MAIN ST
Practice Address - Street 2:NONE
Practice Address - City:MEDWAY
Practice Address - State:MA
Practice Address - Zip Code:02053-1802
Practice Address - Country:US
Practice Address - Phone:508-533-7890
Practice Address - Fax:508-533-7890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA177581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0273201Medicaid