Provider Demographics
NPI:1790967784
Name:KACERIK, MARK G (RDH)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:G
Last Name:KACERIK
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 BOSTON POST ROAD
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516
Mailing Address - Country:US
Mailing Address - Phone:203-931-6029
Mailing Address - Fax:203-931-6083
Practice Address - Street 1:419 BOSTON POST ROAD
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516
Practice Address - Country:US
Practice Address - Phone:203-931-6029
Practice Address - Fax:203-931-6083
Is Sole Proprietor?:No
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004980124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist