Provider Demographics
NPI:1053978221
Name:GOERGY, MARK MINA (DMD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:MINA
Last Name:GOERGY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2460 FAIRMOUNT BLVD STE 218
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44106-3125
Mailing Address - Country:US
Mailing Address - Phone:216-791-5191
Mailing Address - Fax:
Practice Address - Street 1:2460 FAIRMOUNT BLVD STE 218
Practice Address - Street 2:
Practice Address - City:CLEVELAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44106-3125
Practice Address - Country:US
Practice Address - Phone:216-791-5191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-23
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.025815122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist