Provider Demographics
NPI:1992883524
Name:MACDONALD, MARK STEVEN (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:STEVEN
Last Name:MACDONALD
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 1:22944 OUTER DR
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-4279
Mailing Address - Country:US
Mailing Address - Phone:313-563-2522
Mailing Address - Fax:
Practice Address - Street 1:22944 OUTER DR
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-4279
Practice Address - Country:US
Practice Address - Phone:313-563-2522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901014432122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1114906781OtherNPI NUMBER FOR S-CORP