Provider Demographics
NPI:1386328391
Name:MACAK, MARK ANTHONY (DMD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:MACAK
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 1:10330 S 82ND AVE
Mailing Address - Street 2:
Mailing Address - City:PALOS HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60465-1830
Mailing Address - Country:US
Mailing Address - Phone:708-420-3677
Mailing Address - Fax:
Practice Address - Street 1:5701 W MONEE MANHATTAN RD STE 109
Practice Address - Street 2:
Practice Address - City:MONEE
Practice Address - State:IL
Practice Address - Zip Code:60449-8091
Practice Address - Country:US
Practice Address - Phone:708-305-7678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190343271223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice