Provider Demographics
NPI:1104045905
Name:COWAN, MARK R (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:COWAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1107
Mailing Address - Street 2:227 N TALBERT BLVD
Mailing Address - City:LEXINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27292
Mailing Address - Country:US
Mailing Address - Phone:336-249-2906
Mailing Address - Fax:336-249-7988
Practice Address - Street 1:227 N TALBERT BLVD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27292
Practice Address - Country:US
Practice Address - Phone:336-249-2906
Practice Address - Fax:336-249-7988
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC6426122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC9002VMedicaid