Provider Demographics
NPI:1710104211
Name:PURDY, MARK (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:PURDY
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 1:399 SCHAD CT SW
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1203
Mailing Address - Country:US
Mailing Address - Phone:704-787-2015
Mailing Address - Fax:
Practice Address - Street 1:2258 W ROOSEVELT BLVD
Practice Address - Street 2:STE A
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-3089
Practice Address - Country:US
Practice Address - Phone:704-291-7100
Practice Address - Fax:704-291-7115
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC62941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice