Provider Demographics
NPI:1609966324
Name:MARK, JEFFREY ALAN (DMD,MS)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ALAN
Last Name:MARK
Suffix:
Gender:M
Credentials:DMD,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UNIT 33100 BOX LANDSTUHL
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09180-3100
Mailing Address - Country:US
Mailing Address - Phone:314-590-1248
Mailing Address - Fax:
Practice Address - Street 1:UNIT 33100 BOX LANDSTUHL
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09180-3100
Practice Address - Country:US
Practice Address - Phone:314-590-4913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ60701223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics