Provider Demographics
NPI:1699985176
Name:CIVIN, MARK L
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:L
Last Name:CIVIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5600 P.G.A. BLVD
Mailing Address - Street 2:SUITE 102 A
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418
Mailing Address - Country:US
Mailing Address - Phone:772-545-9292
Mailing Address - Fax:
Practice Address - Street 1:5600 PGA BLVD
Practice Address - Street 2:SUITE 102A
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33418-3900
Practice Address - Country:US
Practice Address - Phone:561-624-2224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL84871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice