Provider Demographics
NPI:1043642069
Name:MINTLINE, MARK DOUGLAS (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DOUGLAS
Last Name:MINTLINE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:795 E. SECOND ST.
Mailing Address - Street 2:SUITE 8
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-2007
Mailing Address - Country:US
Mailing Address - Phone:909-706-3910
Mailing Address - Fax:909-469-8650
Practice Address - Street 1:795 E. SECOND ST.
Practice Address - Street 2:SUITE 8
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766
Practice Address - Country:US
Practice Address - Phone:909-706-3910
Practice Address - Fax:909-469-8650
Is Sole Proprietor?:No
Enumeration Date:2013-08-01
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA627021223P0106X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology