Basic Information
Provider Information
NPI: 1003004490
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MARKS
FirstName: RICHARD
MiddleName: IRWIN
NamePrefix:  
NameSuffix:  
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 105 BELLVUE DR
Address2:  
City: FORT WORTH
State: TX
PostalCode: 76134
CountryCode: US
TelephoneNumber: 8172932088
FaxNumber: 8172932088
Practice Location
Address1: 105 BELLVUE DR
Address2:  
City: FORT WORTH
State: TX
PostalCode: 76134
CountryCode: US
TelephoneNumber: 8172932088
FaxNumber: 8172938377
Other Information
ProviderEnumerationDate: 10/10/2007
LastUpdateDate: 10/10/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X6894TXY Dental ProvidersDentist 

No ID Information.


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