Provider Demographics
NPI:1811199284
Name:MARK A SHOUSHA, DDS PC
Entity Type:Organization
Organization Name:MARK A SHOUSHA, DDS PC
Other - Org Name:BAYSHORE DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALFRED
Authorized Official - Last Name:SHOUSHA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-855-4444
Mailing Address - Street 1:1100 N ALMA SCHOOL RD
Mailing Address - Street 2:SUITE 7
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-3171
Mailing Address - Country:US
Mailing Address - Phone:480-855-4444
Mailing Address - Fax:480-857-3866
Practice Address - Street 1:1100 N ALMA SCHOOL RD
Practice Address - Street 2:SUITE 7
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-3171
Practice Address - Country:US
Practice Address - Phone:480-855-4444
Practice Address - Fax:480-857-3866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4329122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty