Provider Demographics
NPI:1912021585
Name:DETERT, MARK ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ROBERT
Last Name:DETERT
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 1:919 SOUTH STATE ROAD 2
Mailing Address - Street 2:
Mailing Address - City:HEBRON
Mailing Address - State:IN
Mailing Address - Zip Code:46341-9539
Mailing Address - Country:US
Mailing Address - Phone:219-996-4171
Mailing Address - Fax:
Practice Address - Street 1:919 SOUTH STATE ROAD 2
Practice Address - Street 2:
Practice Address - City:HEBRON
Practice Address - State:IN
Practice Address - Zip Code:46341-9539
Practice Address - Country:US
Practice Address - Phone:219-996-4171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN7849122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist