Provider Demographics
NPI:1144241589
Name:FLACK, MARK EDWIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWIN
Last Name:FLACK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
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Mailing Address - Street 1:5457 NE WEDGEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64064-1223
Mailing Address - Country:US
Mailing Address - Phone:816-373-7968
Mailing Address - Fax:
Practice Address - Street 1:300 NW RR MIZE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014-2528
Practice Address - Country:US
Practice Address - Phone:816-229-3737
Practice Address - Fax:816-229-1656
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO127001223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1235171059Medicare UPIN