Provider Demographics
NPI:1215779483
Name:RELIQUIAS, MARK (DMD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:RELIQUIAS
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 1:1115 S MINT ST APT 524
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-4099
Mailing Address - Country:US
Mailing Address - Phone:662-528-3815
Mailing Address - Fax:
Practice Address - Street 1:3210 WILKINSON BLVD UNIT B2
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-5662
Practice Address - Country:US
Practice Address - Phone:704-900-5445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-10
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13740122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist