Provider Demographics
NPI:1659527950
Name:GEORGE, MARK D (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:GEORGE
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 1:7770 N UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-4087
Mailing Address - Country:US
Mailing Address - Phone:719-594-9797
Mailing Address - Fax:719-594-6713
Practice Address - Street 1:7770 N UNION BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-4087
Practice Address - Country:US
Practice Address - Phone:719-594-9797
Practice Address - Fax:719-594-6713
Is Sole Proprietor?:No
Enumeration Date:2008-08-18
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9700122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9700OtherCOLORADO DENTAL LICENSE
NE6760OtherNE DENTAL LICENSE