Provider Demographics
NPI:1710104773
Name:BAILEN, MARK LAURENCE (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LAURENCE
Last Name:BAILEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 BILLINGS ST
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:MA
Mailing Address - Zip Code:02067-2140
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:90 PROVIDENCE HWY
Practice Address - Street 2:WALPOLE MALL
Practice Address - City:EAST WALPOLE
Practice Address - State:MA
Practice Address - Zip Code:02032-1524
Practice Address - Country:US
Practice Address - Phone:508-668-1151
Practice Address - Fax:508-668-0640
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17548122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist