Provider Demographics
NPI:1962591644
Name:REDD, MARK J (DDS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:REDD
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 1:25261 PASEO DE VALENCIA
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92637-4966
Mailing Address - Country:US
Mailing Address - Phone:949-581-6641
Mailing Address - Fax:949-581-2831
Practice Address - Street 1:25261 PASEO DE VALENCIA
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92637-4966
Practice Address - Country:US
Practice Address - Phone:949-581-6641
Practice Address - Fax:949-581-2831
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA444381223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics