Provider Demographics
NPI:1336266436
Name:LAVIN, MARK THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:THOMAS
Last Name:LAVIN
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 1:4703 W COTTAGE TRL
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-2185
Mailing Address - Country:US
Mailing Address - Phone:605-521-0454
Mailing Address - Fax:
Practice Address - Street 1:6104 S LYNCREST AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-2560
Practice Address - Country:US
Practice Address - Phone:605-332-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM9811223P0300X
NE64271223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics