Provider Demographics
NPI:1831174556
Name:DUCKETT, MARK A
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:DUCKETT
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:A
Other - Last Name:DUCKETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:8300 AUBURN FOLSOM RD
Mailing Address - Street 2:
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-9381
Mailing Address - Country:US
Mailing Address - Phone:916-561-7800
Mailing Address - Fax:
Practice Address - Street 1:4101 ARNOLD AVE
Practice Address - Street 2:VA /MCCLELLAN DENTAL SERVICE
Practice Address - City:SCRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95652
Practice Address - Country:US
Practice Address - Phone:916-561-7800
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA437801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice