Provider Demographics
NPI:1922168814
Name:DONOVAN, MARK T (DDS MS)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:T
Last Name:DONOVAN
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 N PANTANO RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710
Mailing Address - Country:US
Mailing Address - Phone:520-290-8787
Mailing Address - Fax:520-290-2278
Practice Address - Street 1:150 N PANTANO RD
Practice Address - Street 2:SUITE 100
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710
Practice Address - Country:US
Practice Address - Phone:520-290-8787
Practice Address - Fax:520-290-2278
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2865122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist