Provider Demographics
NPI:1285806141
Name:MARK J. MROCH, DDS,DENTAL CORP.
Entity type:Organization
Organization Name:MARK J. MROCH, DDS,DENTAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:MROCH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-639-9800
Mailing Address - Street 1:112 N MCPHERSON RD
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92869-3721
Mailing Address - Country:US
Mailing Address - Phone:714-639-9800
Mailing Address - Fax:714-639-9899
Practice Address - Street 1:112 N MCPHERSON RD
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92869-3721
Practice Address - Country:US
Practice Address - Phone:714-639-9800
Practice Address - Fax:714-639-9899
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MROCH MERIDIAN DENTAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-31
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADG33961122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB33961Medicaid