Provider Demographics
NPI:1881763795
Name:ROMANELLI, MARK JAMES (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:JAMES
Last Name:ROMANELLI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4555 EL CAMINO REAL
Mailing Address - Street 2:STE. D
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-2700
Mailing Address - Country:US
Mailing Address - Phone:805-461-1772
Mailing Address - Fax:805-461-0514
Practice Address - Street 1:4555 EL CAMINO REAL
Practice Address - Street 2:STE. D
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-2700
Practice Address - Country:US
Practice Address - Phone:805-461-1772
Practice Address - Fax:805-461-0514
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0348931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice