Provider Demographics
NPI:1730879396
Name:DIMITRIU, MARK ALEXANDER (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALEXANDER
Last Name:DIMITRIU
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 1:13700 N US HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-8980
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13700 N US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-8980
Practice Address - Country:US
Practice Address - Phone:352-259-0822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-08
Last Update Date:2025-08-25
Deactivation Date:2025-08-10
Deactivation Code:
Reactivation Date:2025-08-25
Provider Licenses
StateLicense IDTaxonomies
FLDN308081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty