Provider Demographics
NPI:1891363966
Name:MARK, BRANDON (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:
Last Name:MARK
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 1:3600 PARK EAST DR APT 408
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-4355
Mailing Address - Country:US
Mailing Address - Phone:216-910-8873
Mailing Address - Fax:
Practice Address - Street 1:3515 HUDSON DR STE 100
Practice Address - Street 2:
Practice Address - City:STOW
Practice Address - State:OH
Practice Address - Zip Code:44224-6968
Practice Address - Country:US
Practice Address - Phone:330-928-7674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.026542122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty