Provider Demographics
NPI:1801889209
Name:WIATT, MARK (DDS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WIATT
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 1:255 HWY 187
Mailing Address - Street 2:PO BOX 370
Mailing Address - City:HATCH
Mailing Address - State:NM
Mailing Address - Zip Code:87937-0730
Mailing Address - Country:US
Mailing Address - Phone:505-267-3088
Mailing Address - Fax:505-267-1747
Practice Address - Street 1:1960 N DATE ST
Practice Address - Street 2:
Practice Address - City:T OR C
Practice Address - State:NM
Practice Address - Zip Code:87901-3701
Practice Address - Country:US
Practice Address - Phone:505-267-3088
Practice Address - Fax:505-267-1747
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD-2602122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM92422071Medicaid