Provider Demographics
NPI:1336225440
Name:EISEN, MARK Z
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:Z
Last Name:EISEN
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:Z
Other - Last Name:EISEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:10 N GREENE ST
Mailing Address - Street 2:BALTIMORE VA MEDICAL CENTER DENTAL DEPARTMENT
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1524
Mailing Address - Country:US
Mailing Address - Phone:410-605-7056
Mailing Address - Fax:410-605-7819
Practice Address - Street 1:10 N GREENE ST
Practice Address - Street 2:BALTIMORE VA MEDICAL CENTER DENTAL DEPARTMENT
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1524
Practice Address - Country:US
Practice Address - Phone:410-605-7056
Practice Address - Fax:410-605-7819
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD54291223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDT59710Medicare UPIN