Provider Demographics
NPI:1194255513
Name:DUFFY, MARK ROBERT (DMD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ROBERT
Last Name:DUFFY
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 1:2780 AIRPORT DR STE 100
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219-2289
Mailing Address - Country:US
Mailing Address - Phone:614-859-1906
Mailing Address - Fax:614-645-5517
Practice Address - Street 1:2300 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-3783
Practice Address - Country:US
Practice Address - Phone:614-645-2300
Practice Address - Fax:614-645-5517
Is Sole Proprietor?:No
Enumeration Date:2017-06-18
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0251121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice