Provider Demographics
NPI:1841382520
Name:LARUE, MARK GRIFFITH (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:GRIFFITH
Last Name:LARUE
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 1:2011-A BEES FERRY ROAD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414
Mailing Address - Country:US
Mailing Address - Phone:843-852-0780
Mailing Address - Fax:843-852-0788
Practice Address - Street 1:2011-A BEES FERRY ROAD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414
Practice Address - Country:US
Practice Address - Phone:843-852-0780
Practice Address - Fax:843-852-0788
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3225122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC232251Medicaid
SCZ32251Medicaid