Provider Demographics
NPI:1699804633
Name:ELFERVIG, MARK THOMAS (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:THOMAS
Last Name:ELFERVIG
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 1:709 86TH STREET CT NW
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-9791
Mailing Address - Country:US
Mailing Address - Phone:941-795-8983
Mailing Address - Fax:
Practice Address - Street 1:1906 59TH ST W STE A
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-4639
Practice Address - Country:US
Practice Address - Phone:941-795-0144
Practice Address - Fax:941-795-7188
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 111881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice