Provider Demographics
NPI:1912648619
Name:DAGHER, MARK SIMON (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:SIMON
Last Name:DAGHER
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 1:5255 STILESBORO RD NW STE 150
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-7738
Mailing Address - Country:US
Mailing Address - Phone:770-794-3332
Mailing Address - Fax:
Practice Address - Street 1:5255 STILESBORO RD NW STE 150
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-7738
Practice Address - Country:US
Practice Address - Phone:770-794-3332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD011548122300000X
GADN123568122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty