Provider Demographics
NPI:1093221772
Name:DR MARK D LAND DMD PC
Entity Type:Organization
Organization Name:DR MARK D LAND DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-698-8113
Mailing Address - Street 1:PO BOX 661
Mailing Address - Street 2:
Mailing Address - City:SULLIGENT
Mailing Address - State:AL
Mailing Address - Zip Code:35586-0661
Mailing Address - Country:US
Mailing Address - Phone:205-698-8113
Mailing Address - Fax:
Practice Address - Street 1:445 FRONT STREET
Practice Address - Street 2:
Practice Address - City:SULLIGENT
Practice Address - State:AL
Practice Address - Zip Code:35586
Practice Address - Country:US
Practice Address - Phone:205-698-8113
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-18
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL47141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty