Provider Demographics
NPI:1669514477
Name:PRIMO, DAVID MARK (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MARK
Last Name:PRIMO
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 1:170 FLANDERS RD
Mailing Address - Street 2:
Mailing Address - City:NIANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06357-1208
Mailing Address - Country:US
Mailing Address - Phone:860-739-9862
Mailing Address - Fax:860-739-6558
Practice Address - Street 1:170 FLANDERS RD
Practice Address - Street 2:
Practice Address - City:NIANTIC
Practice Address - State:CT
Practice Address - Zip Code:06357-1208
Practice Address - Country:US
Practice Address - Phone:860-739-9862
Practice Address - Fax:860-739-6558
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT44991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice