1962654889 NPI number — MARK J CASTLE DDS

Table of content: MARK J CASTLE DDS (NPI 1962654889)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962654889 NPI number — MARK J CASTLE DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASTLE
Provider First Name:
MARK
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962654889
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/05/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
138 CELILO ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLAGSTAFF
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86001-9531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-525-9263
Provider Business Mailing Address Fax Number:
928-525-9338

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2700 S WOODLANDS VILLAGE BLVD
Provider Second Line Business Practice Location Address:
SUITE 390
Provider Business Practice Location Address City Name:
FLAGSTAFF
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86001-7114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-226-7654
Provider Business Practice Location Address Fax Number:
928-226-7373
Provider Enumeration Date:
10/22/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  D2897 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)