Basic Information
Provider Information | |||||||||
NPI: | 1326135880 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRAITHWAITE | ||||||||
FirstName: | MARK | ||||||||
MiddleName: | WINSTON | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.D.S., M.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 159 MIDWOOD ST | ||||||||
Address2: |   | ||||||||
City: | BROOKLYN | ||||||||
State: | NY | ||||||||
PostalCode: | 112255060 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7182876756 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 950 CAMPBELL AVE | ||||||||
Address2: | VA CONNECTICUT HEALTHCARE SYSTEM, DENTAL SERVICE 160 | ||||||||
City: | WEST HAVEN | ||||||||
State: | CT | ||||||||
PostalCode: | 065162770 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2039325711 | ||||||||
FaxNumber: | 2039374895 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/06/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0300X | 19024487 | IL | Y |   | Dental Providers | Dentist | Periodontics |
No ID Information.