Provider Demographics
NPI:1023556743
Name:HUMPHREY, MARK (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:HUMPHREY
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8657 OLD BONHOMME RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-3901
Mailing Address - Country:US
Mailing Address - Phone:636-734-6896
Mailing Address - Fax:
Practice Address - Street 1:8657 OLD BONHOMME RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63132-3901
Practice Address - Country:US
Practice Address - Phone:636-734-6896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-01
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20140168051223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics