Provider Demographics
NPI:1912044892
Name:GAYNOR, MARK ALBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALBERT
Last Name:GAYNOR
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 1:42611 GARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1653
Mailing Address - Country:US
Mailing Address - Phone:586-228-7766
Mailing Address - Fax:586-228-1510
Practice Address - Street 1:42611 GARFIELD RD
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-1653
Practice Address - Country:US
Practice Address - Phone:586-228-7766
Practice Address - Fax:586-228-1510
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0156031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice