Provider Demographics
NPI:1720095631
Name:HABERMEYER, MARK HENRY (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:HENRY
Last Name:HABERMEYER
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 1:4115 RIVERDALE RD STE B
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84405-3509
Mailing Address - Country:US
Mailing Address - Phone:801-940-5555
Mailing Address - Fax:384-206-8383
Practice Address - Street 1:4115 RIVERDALE RD STE B
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:UT
Practice Address - Zip Code:84405-3509
Practice Address - Country:US
Practice Address - Phone:801-940-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9231171-9921122300000X
CA269941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT9231171-9921OtherSTATE OF UTAH DEPARTMENT OF COMMERCE
CA508064OtherDENTICAL