Provider Demographics
NPI:1700515277
Name:DE PEDRO, MARK PHILLIP (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:PHILLIP
Last Name:DE PEDRO
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 1:18326 CYPRESS LAKE VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77429-3969
Mailing Address - Country:US
Mailing Address - Phone:832-660-3940
Mailing Address - Fax:
Practice Address - Street 1:25450 KUYKENDAHL RD STE 100
Practice Address - Street 2:
Practice Address - City:TOMBALL
Practice Address - State:TX
Practice Address - Zip Code:77375-3436
Practice Address - Country:US
Practice Address - Phone:832-791-1010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-08
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38462122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist