Provider Demographics
NPI:1063021376
Name:ZAVALA, MARK (DMD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ZAVALA
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 1:600 TECHNOLOGY PARK STE 101
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-7122
Mailing Address - Country:US
Mailing Address - Phone:407-543-8509
Mailing Address - Fax:
Practice Address - Street 1:4732 S KIRKMAN RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32811-3643
Practice Address - Country:US
Practice Address - Phone:407-292-7373
Practice Address - Fax:407-992-8858
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN248841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice