Provider Demographics
NPI:1588693170
Name:GJERDE, MARK LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:LEE
Last Name:GJERDE
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 1:11841 RINGWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:CA
Mailing Address - Zip Code:95693-9638
Mailing Address - Country:US
Mailing Address - Phone:916-687-6513
Mailing Address - Fax:
Practice Address - Street 1:8880 ELK GROVE BLVD
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-1832
Practice Address - Country:US
Practice Address - Phone:916-685-2141
Practice Address - Fax:916-685-6449
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA257111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice