Provider Demographics
NPI:1689636722
Name:VINCENT, MARK BLAINE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:BLAINE
Last Name:VINCENT
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 1:3185 MERRIMAN ST
Mailing Address - Street 2:
Mailing Address - City:PORT NECHES
Mailing Address - State:TX
Mailing Address - Zip Code:77651-6002
Mailing Address - Country:US
Mailing Address - Phone:409-729-2303
Mailing Address - Fax:409-729-2307
Practice Address - Street 1:3185 MERRIMAN ST
Practice Address - Street 2:
Practice Address - City:PORT NECHES
Practice Address - State:TX
Practice Address - Zip Code:77651-6002
Practice Address - Country:US
Practice Address - Phone:409-729-2303
Practice Address - Fax:409-729-2307
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX132871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice