Provider Demographics
NPI:1942496278
Name:MARK LASZLO, DDS, PC
Entity Type:Organization
Organization Name:MARK LASZLO, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:LASZLO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-674-4171
Mailing Address - Street 1:4624 W WALTON BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-3566
Mailing Address - Country:US
Mailing Address - Phone:248-674-4171
Mailing Address - Fax:248-674-7372
Practice Address - Street 1:4624 W WALTON BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329-3566
Practice Address - Country:US
Practice Address - Phone:248-674-4171
Practice Address - Fax:248-674-7372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010144281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty