Provider Demographics
NPI:1871556233
Name:SEVERINO, MARK (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:SEVERINO
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 1:1145 TARGEE ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-4323
Mailing Address - Country:US
Mailing Address - Phone:718-667-4800
Mailing Address - Fax:718-667-7292
Practice Address - Street 1:1145 TARGEE ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-4323
Practice Address - Country:US
Practice Address - Phone:718-667-4800
Practice Address - Fax:718-667-7292
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0405341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice