Provider Demographics
NPI:1063592939
Name:PRESTWICH, MARK LYN (DMD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:LYN
Last Name:PRESTWICH
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 1:2402 WOODBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-2158
Mailing Address - Country:US
Mailing Address - Phone:770-926-2358
Mailing Address - Fax:
Practice Address - Street 1:1744 ROSWELL RD
Practice Address - Street 2:STE.#310
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-3979
Practice Address - Country:US
Practice Address - Phone:770-973-8183
Practice Address - Fax:770-565-3961
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA010237122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist