Provider Demographics
NPI:1902028657
Name:JUDY, MARK ANDREW (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANDREW
Last Name:JUDY
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 1:330 PARK AVE
Mailing Address - Street 2:STE 5
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-2352
Mailing Address - Country:US
Mailing Address - Phone:949-494-4814
Mailing Address - Fax:949-494-2142
Practice Address - Street 1:330 PARK AVE
Practice Address - Street 2:STE 5
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-2352
Practice Address - Country:US
Practice Address - Phone:949-494-4814
Practice Address - Fax:949-494-2142
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA229901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice