Provider Demographics
NPI:1932586104
Name:JAMISON, MARK
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:JAMISON
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 1:9100 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 301E
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-3415
Mailing Address - Country:US
Mailing Address - Phone:310-274-8811
Mailing Address - Fax:310-274-3660
Practice Address - Street 1:9100 WILSHIRE BLVD
Practice Address - Street 2:SUITE 301E
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-3415
Practice Address - Country:US
Practice Address - Phone:310-274-8811
Practice Address - Fax:310-274-3660
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-27
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47487122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist