Provider Demographics
NPI:1811943798
Name:JANOSKY, MARK J (DMD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:JANOSKY
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:P.O. BOX 547
Mailing Address - Street 2:
Mailing Address - City:LITTLE RIVER
Mailing Address - State:SC
Mailing Address - Zip Code:29566-0547
Mailing Address - Country:US
Mailing Address - Phone:843-663-8000
Mailing Address - Fax:843-663-8123
Practice Address - Street 1:4220 CAROLINA EXCHANGE DRIVE
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-4220
Practice Address - Country:US
Practice Address - Phone:843-663-8000
Practice Address - Fax:843-663-8123
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC79331223G0001X
SC4418122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC9021POtherBLUECROSS BLUESHIELD
NC5900834Medicaid
V05339Medicare UPIN
NC5900834Medicaid