Provider Demographics
NPI:1962192187
Name:HENEIN, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:HENEIN
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 1:1211 N GARDEN AVE
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33755-2427
Mailing Address - Country:US
Mailing Address - Phone:727-710-9903
Mailing Address - Fax:
Practice Address - Street 1:379 KINGS HWY UNIT 300
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33983-5261
Practice Address - Country:US
Practice Address - Phone:941-467-3321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-10
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL281661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice