Provider Demographics
NPI:1467425546
Name:DETTELBACH, MARK ARTHUR (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ARTHUR
Last Name:DETTELBACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6201 GREENLEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2004
Mailing Address - Country:US
Mailing Address - Phone:410-933-2704
Mailing Address - Fax:410-500-4266
Practice Address - Street 1:5454 WISCONSIN AVE
Practice Address - Street 2:SUITE 1535
Practice Address - City:CHEVY CHASE
Practice Address - State:MD
Practice Address - Zip Code:20815-6901
Practice Address - Country:US
Practice Address - Phone:301-652-8847
Practice Address - Fax:301-652-8320
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD47278174400000X
DCMD21258207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG11434Medicare ID - Type Unspecified