Provider Demographics
NPI:1043256985
Name:ICARD, MARK WINSLOW (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:WINSLOW
Last Name:ICARD
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 1:5500 HIGHWAY 49 S
Mailing Address - Street 2:SUITE 500
Mailing Address - City:HARRISBURG
Mailing Address - State:NC
Mailing Address - Zip Code:28075-8414
Mailing Address - Country:US
Mailing Address - Phone:704-455-5003
Mailing Address - Fax:704-455-3587
Practice Address - Street 1:5500 HIGHWAY 49 S
Practice Address - Street 2:SUITE 500
Practice Address - City:HARRISBURG
Practice Address - State:NC
Practice Address - Zip Code:28075-8414
Practice Address - Country:US
Practice Address - Phone:704-455-5003
Practice Address - Fax:704-455-3587
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC56681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC94419OtherBCBS PROVIDER ID
NC8994419Medicaid