Provider Demographics
NPI:1669502589
Name:NIEMIEC, MARK A (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:NIEMIEC
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1399 WEIMER RD
Mailing Address - Street 2:SUITE 800
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6340
Mailing Address - Country:US
Mailing Address - Phone:505-758-9777
Mailing Address - Fax:505-758-9413
Practice Address - Street 1:1399 WEIMER RD
Practice Address - Street 2:SUITE 800
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6340
Practice Address - Country:US
Practice Address - Phone:505-758-9777
Practice Address - Fax:505-758-9413
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD17971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM976951OtherUNITED CONCORDIA PROVIDER
NM105266Medicaid