Provider Demographics
NPI:1013063866
Name:MEREDITH, MARK M (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:M
Last Name:MEREDITH
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 1:2914 BETIN AVENUE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-7495
Mailing Address - Country:US
Mailing Address - Phone:318-388-1250
Mailing Address - Fax:318-388-0948
Practice Address - Street 1:2914 BETIN AVENUE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-7495
Practice Address - Country:US
Practice Address - Phone:318-388-1250
Practice Address - Fax:318-388-0948
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA30061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice