Provider Demographics
NPI:1407231798
Name:JUAREZ, MARK T (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:T
Last Name:JUAREZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10316 GODDARD ST APT 119
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66214-3079
Mailing Address - Country:US
Mailing Address - Phone:614-439-7472
Mailing Address - Fax:
Practice Address - Street 1:1731 E NORTH AVE
Practice Address - Street 2:
Practice Address - City:BELTON
Practice Address - State:MO
Practice Address - Zip Code:64012-2130
Practice Address - Country:US
Practice Address - Phone:816-322-3506
Practice Address - Fax:816-322-3282
Is Sole Proprietor?:No
Enumeration Date:2015-07-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS61252122300000X
MO20170159641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist