Provider Demographics
NPI:1285941005
Name:MARK A. GEORGE D.D.S., INC
Entity type:Organization
Organization Name:MARK A. GEORGE D.D.S., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:LESLIE
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-953-1000
Mailing Address - Street 1:1140 W LA VETA AVE STE 530
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4227
Mailing Address - Country:US
Mailing Address - Phone:714-953-1000
Mailing Address - Fax:714-953-9957
Practice Address - Street 1:1140 W LA VETA AVE STE 530
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4227
Practice Address - Country:US
Practice Address - Phone:714-953-1000
Practice Address - Fax:714-953-9957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-01
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA311421223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty