Provider Demographics
NPI:1003026782
Name:CHASE, MARK THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:THOMAS
Last Name:CHASE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:8424 W CENTER RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-3138
Mailing Address - Country:US
Mailing Address - Phone:402-397-1300
Mailing Address - Fax:402-397-6449
Practice Address - Street 1:8424 W CENTER RD
Practice Address - Street 2:SUITE 100
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-3138
Practice Address - Country:US
Practice Address - Phone:402-397-1300
Practice Address - Fax:402-397-6449
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE54561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47-0736187-00Medicaid