Provider Demographics
NPI:1649355173
Name:GRECCO, MARK ADRIAN (DMD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ADRIAN
Last Name:GRECCO
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 1:1511 WEST YOSEMITE AVE.
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337
Mailing Address - Country:US
Mailing Address - Phone:209-824-7230
Mailing Address - Fax:
Practice Address - Street 1:1511 WEST YOSEMITE AVE.
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337
Practice Address - Country:US
Practice Address - Phone:209-824-7230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA346141223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU43134Medicare UPIN