Provider Demographics
NPI:1265579866
Name:LASSITER, MARK DAVID SR (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:LASSITER
Suffix:SR
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 1:8487 S SCENIC HWY
Mailing Address - Street 2:
Mailing Address - City:BLAND
Mailing Address - State:VA
Mailing Address - Zip Code:24315-4691
Mailing Address - Country:US
Mailing Address - Phone:276-688-4711
Mailing Address - Fax:276-688-4712
Practice Address - Street 1:8487 S SCENIC HWY
Practice Address - Street 2:
Practice Address - City:BLAND
Practice Address - State:VA
Practice Address - Zip Code:24315-4691
Practice Address - Country:US
Practice Address - Phone:276-688-4711
Practice Address - Fax:276-688-4712
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6451122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8995126Medicaid