Provider Demographics
NPI:1841331097
Name:DERKAZARIAN, MARK CHARLES (DMD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:CHARLES
Last Name:DERKAZARIAN
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 1:1692 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-1803
Mailing Address - Country:US
Mailing Address - Phone:617-864-5444
Mailing Address - Fax:617-576-0109
Practice Address - Street 1:1692 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-1803
Practice Address - Country:US
Practice Address - Phone:617-864-5444
Practice Address - Fax:617-576-0109
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA204941223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics