Provider Demographics
NPI:1871521369
Name:DIAMOND, MARK JOHN (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOHN
Last Name:DIAMOND
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 1:500 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-7646
Mailing Address - Country:US
Mailing Address - Phone:207-883-4285
Mailing Address - Fax:207-883-9891
Practice Address - Street 1:500 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-7646
Practice Address - Country:US
Practice Address - Phone:207-883-4285
Practice Address - Fax:207-883-9891
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME33211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice