Provider Demographics
NPI:1215025127
Name:KNOLLMAN, MARK A (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:KNOLLMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 B CENTREPARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28805
Mailing Address - Country:US
Mailing Address - Phone:828-254-5677
Mailing Address - Fax:828-254-1468
Practice Address - Street 1:600 B CENTREPARK DRIVE
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28805
Practice Address - Country:US
Practice Address - Phone:828-254-5677
Practice Address - Fax:828-254-1468
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC57201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8995064Medicaid