Provider Demographics
NPI:1811012776
Name:GIANATASSIO, MARK JOSEPH (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JOSEPH
Last Name:GIANATASSIO
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 1:820 LYNN FELLS PKWY
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176
Mailing Address - Country:US
Mailing Address - Phone:781-979-0235
Mailing Address - Fax:781-979-0230
Practice Address - Street 1:820 LYNN FELLS
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176
Practice Address - Country:US
Practice Address - Phone:781-979-0235
Practice Address - Fax:781-979-0230
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16926122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist