Provider Demographics
NPI:1215056551
Name:URBANE, MARK EDWARD (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:URBANE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5820 MENAUL BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-3238
Mailing Address - Country:US
Mailing Address - Phone:505-884-6408
Mailing Address - Fax:505-872-3065
Practice Address - Street 1:5820 MENAUL BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-3238
Practice Address - Country:US
Practice Address - Phone:505-884-6408
Practice Address - Fax:505-872-3065
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM16811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM80309Medicaid