Provider Demographics
NPI:1679004725
Name:PERSAUD, MARK (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:PERSAUD
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 1:2005 IVY RIDGE RD SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-3135
Mailing Address - Country:US
Mailing Address - Phone:347-598-2410
Mailing Address - Fax:
Practice Address - Street 1:6600 PEACHTREE DUNWOODY RD
Practice Address - Street 2:BUILDING 400 SUITE 150
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30328-3032
Practice Address - Country:US
Practice Address - Phone:347-598-2410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-21
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN015599122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist