Provider Demographics
NPI:1720199060
Name:MISCAVAGE, MARK F (DMD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:F
Last Name:MISCAVAGE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18701-1602
Mailing Address - Country:US
Mailing Address - Phone:570-825-4413
Mailing Address - Fax:570-825-4414
Practice Address - Street 1:91 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18701-1602
Practice Address - Country:US
Practice Address - Phone:570-825-4413
Practice Address - Fax:570-825-4414
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS024079L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist