Provider Demographics
NPI:1154614493
Name:STEWART, MARK
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:STEWART
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:CROMWELL
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:22 NELSON AVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-6744
Mailing Address - Country:US
Mailing Address - Phone:321-254-5232
Mailing Address - Fax:321-254-7755
Practice Address - Street 1:22 NELSON AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-6744
Practice Address - Country:US
Practice Address - Phone:321-254-5232
Practice Address - Fax:321-254-7755
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-19
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN101731223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics