Provider Demographics
NPI:1356878227
Name:MEDEIROS, MARK ANTHONY (DMD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANTHONY
Last Name:MEDEIROS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-2155
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:227 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02703-5554
Practice Address - Country:US
Practice Address - Phone:774-282-4206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1857564122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist