Provider Demographics
NPI:1841252996
Name:GLEISNER, MARK RICHARD (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:RICHARD
Last Name:GLEISNER
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 1:2 ND FLOOR BLDG 9900
Mailing Address - Street 2:ATTN: CREDENTIALS OFFICE
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-0001
Mailing Address - Country:US
Mailing Address - Phone:253-968-4039
Mailing Address - Fax:
Practice Address - Street 1:2 ND FLOOR BLDG 9900
Practice Address - Street 2:ATTN: CREDENTIALS OFFICE
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-968-4039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND106421223P0106X
WI5388-151223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology