Provider Demographics
NPI:1821202938
Name:SARDO, MARK RICHARD (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:RICHARD
Last Name:SARDO
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 1:2323 PARKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4720
Mailing Address - Country:US
Mailing Address - Phone:912-265-7193
Mailing Address - Fax:912-265-6799
Practice Address - Street 1:2323 PARKWOOD DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4720
Practice Address - Country:US
Practice Address - Phone:912-265-7193
Practice Address - Fax:912-265-6799
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0101701223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA821940OtherUNITED CONCORDIA PROVIDER