Provider Demographics
NPI:1972211134
Name:MARK A. MASTELLOTTO
Entity Type:Organization
Organization Name:MARK A. MASTELLOTTO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:MASTELLOTTO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:517-263-0338
Mailing Address - Street 1:760 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-1445
Mailing Address - Country:US
Mailing Address - Phone:517-263-0338
Mailing Address - Fax:517-263-1138
Practice Address - Street 1:760 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1445
Practice Address - Country:US
Practice Address - Phone:517-263-0338
Practice Address - Fax:517-263-1138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
1013077601OtherALL INSURANCE
MI1013077601OtherALL INSURANCE
MI1013077601Medicaid
MI1013077601OtherDENTAL