Basic Information
| Provider Information | |||||||||
| NPI: | 1467447136 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARKS | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | PHILIP | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 BROOKDALE PLZ STE 666 | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112123198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182407143 | ||||||||
| FaxNumber: | 7182405808 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 BROOKDALE PLZ | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112123139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182406281 | ||||||||
| FaxNumber: | 7182405808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2005 | ||||||||
| LastUpdateDate: | 04/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | 36194 | NY | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00856313 | 05 | NY | MEDICAID |