Provider Demographics
NPI:1386695138
Name:GENTNER, MARK A (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:GENTNER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:62843 BROADMOOR CIRCLE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48094
Mailing Address - Country:US
Mailing Address - Phone:586-786-5841
Mailing Address - Fax:
Practice Address - Street 1:5556 METROPOLITAN PARKWAY
Practice Address - Street 2:SUITE B
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310
Practice Address - Country:US
Practice Address - Phone:586-939-5980
Practice Address - Fax:586-939-3409
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI134581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI432635OtherUNITED CONCORDIA PROVIDER