Provider Demographics
NPI:1073765137
Name:DRENTLAW, MARK T (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:T
Last Name:DRENTLAW
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 PARK HILL LN
Mailing Address - Street 2:
Mailing Address - City:SUTHERLIN
Mailing Address - State:OR
Mailing Address - Zip Code:97479-9022
Mailing Address - Country:US
Mailing Address - Phone:541-802-1040
Mailing Address - Fax:541-802-1042
Practice Address - Street 1:325 PARK HILL LN
Practice Address - Street 2:
Practice Address - City:SUTHERLIN
Practice Address - State:OR
Practice Address - Zip Code:97479-9022
Practice Address - Country:US
Practice Address - Phone:541-802-1040
Practice Address - Fax:541-802-1042
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2294111N00000X
OR6100111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty