Provider Demographics
NPI:1588781637
Name:MROCH, MARK J (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:MROCH
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 1:112 N MCPHERSON RD
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92869-3721
Mailing Address - Country:US
Mailing Address - Phone:714-639-9800
Mailing Address - Fax:714-639-9899
Practice Address - Street 1:112 N MCPHERSON RD
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92869-3721
Practice Address - Country:US
Practice Address - Phone:714-639-9800
Practice Address - Fax:714-639-9899
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADG 33961122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADG33961OtherSTATE LICENSE
CAB33961 01Medicaid
CA330260732OtherTIN