Provider Demographics
NPI:1265565253
Name:SUTOR, MARK A (DDS MSD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:SUTOR
Suffix:
Gender:M
Credentials:DDS MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:379 S PARK RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-8574
Mailing Address - Country:US
Mailing Address - Phone:812-333-4550
Mailing Address - Fax:812-333-5789
Practice Address - Street 1:379 S PARK RIDGE RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-8574
Practice Address - Country:US
Practice Address - Phone:812-333-4550
Practice Address - Fax:812-333-5789
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120092691223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics