Provider Demographics
NPI:1710063631
Name:AZZOPARDI, MARK ANTHONY (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANTHONY
Last Name:AZZOPARDI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:39595 W 10 MILE RD
Mailing Address - Street 2:#107
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-2948
Mailing Address - Country:US
Mailing Address - Phone:248-476-0800
Mailing Address - Fax:248-476-5531
Practice Address - Street 1:39595 W 10 MILE RD
Practice Address - Street 2:#107
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-2948
Practice Address - Country:US
Practice Address - Phone:248-476-0800
Practice Address - Fax:248-476-5531
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010131221223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU50526Medicare UPIN
MI5636238Medicare ID - Type Unspecified