Provider Demographics
NPI:1093795122
Name:MCDONALD, MARK NEWTON (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:NEWTON
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:BLDG 2441 21ST STREET
Mailing Address - Street 2:USA DENTAC
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-5369
Mailing Address - Country:US
Mailing Address - Phone:270-798-8614
Mailing Address - Fax:270-798-8633
Practice Address - Street 1:BLDG 2441 21ST STREET
Practice Address - Street 2:USA DENTAC
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5369
Practice Address - Country:US
Practice Address - Phone:270-798-8614
Practice Address - Fax:270-798-8633
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MODE014689122300000X, 1223G0001X
TX175881223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223G0001XDental ProvidersDentistGeneral Practice