Provider Demographics
NPI:1053409680
Name:LENZ, MARK D (DDS, MS, SC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:LENZ
Suffix:
Gender:M
Credentials:DDS, MS, SC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 SPRING LAKE DR
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-4926
Mailing Address - Country:US
Mailing Address - Phone:262-634-6900
Mailing Address - Fax:262-634-6786
Practice Address - Street 1:1558 S GREENBAY RD
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-4410
Practice Address - Country:US
Practice Address - Phone:262-634-6900
Practice Address - Fax:262-634-6786
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2987-0151223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics