Provider Demographics
NPI:1992729628
Name:MARK, ANDREI (DDS)
Entity type:Individual
Prefix:DR
First Name:ANDREI
Middle Name:
Last Name:MARK
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 1:57 W 57TH ST
Mailing Address - Street 2:SUITE#1004
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-2802
Mailing Address - Country:US
Mailing Address - Phone:212-813-0707
Mailing Address - Fax:212-813-0808
Practice Address - Street 1:57 W 57TH ST
Practice Address - Street 2:SUITE#1004
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-2802
Practice Address - Country:US
Practice Address - Phone:212-813-0707
Practice Address - Fax:212-813-0808
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0410221223P0106X, 1223S0112X, 1223X0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Not Answered1223X0008XDental ProvidersDentistOral and Maxillofacial Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY112542OtherCIGNA HMO