Provider Demographics
NPI:1811074974
Name:STEWART, MARK IVAN (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:IVAN
Last Name:STEWART
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 1:821 KING GEORGE BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31419-8328
Mailing Address - Country:US
Mailing Address - Phone:912-925-5440
Mailing Address - Fax:912-925-6627
Practice Address - Street 1:821 KING GEORGE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-8328
Practice Address - Country:US
Practice Address - Phone:912-925-5440
Practice Address - Fax:912-925-6627
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0110581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice