Basic Information
| Provider Information | |||||||||
| NPI: | 1902354772 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WARNER | ||||||||
| FirstName: | MARK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1175 HART AVE. | ||||||||
| Address2: | BRANCH DENTAL CLINIC YUMA | ||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85369 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2005 KNIGHT LANE BLDG H | ||||||||
| Address2: | NAVY MEDICINE SUPPORT COMMAND ATTN: MEDICAL STAFF SVCS | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322120140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607253213 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2016 | ||||||||
| LastUpdateDate: | 09/21/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 7136-15 | WI | Y | Dental Providers | Dentist |
No ID Information.