Provider Demographics
NPI:1962597930
Name:LUSTMAN, MARK ALLAN (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLAN
Last Name:LUSTMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:MORRIS
Other - Middle Name:ABRAHAM
Other - Last Name:LUSTMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:621 STEMMERS RUN RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21221-3386
Mailing Address - Country:US
Mailing Address - Phone:410-574-9400
Mailing Address - Fax:410-574-3787
Practice Address - Street 1:621 STEMMERS RUN RD
Practice Address - Street 2:SUITE D
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21221-3386
Practice Address - Country:US
Practice Address - Phone:410-574-9400
Practice Address - Fax:410-574-3787
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD52191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice