Provider Demographics
NPI:1306973177
Name:CIOVACCO, MARK GEORGE (DMD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:GEORGE
Last Name:CIOVACCO
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 1:15 REDONDO DRIVE
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603
Mailing Address - Country:US
Mailing Address - Phone:845-473-5049
Mailing Address - Fax:845-471-3955
Practice Address - Street 1:15 REDONDO DRIVE
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603
Practice Address - Country:US
Practice Address - Phone:845-473-5049
Practice Address - Fax:845-471-3955
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0340891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00569936Medicaid