Provider Demographics
NPI:1104962265
Name:TODD, MARK W (DMD, PA)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:TODD
Suffix:
Gender:M
Credentials:DMD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 PREVATT ST STE A
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-6149
Mailing Address - Country:US
Mailing Address - Phone:352-589-5009
Mailing Address - Fax:352-589-5020
Practice Address - Street 1:2000 PREVATT ST STE A
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-6149
Practice Address - Country:US
Practice Address - Phone:352-589-5009
Practice Address - Fax:352-589-5020
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN-00125641223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL46-4472264Medicare UPIN