Provider Demographics
NPI:1225035207
Name:HAMM, MARK W (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:HAMM
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 1:1381 SE MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-4373
Mailing Address - Country:US
Mailing Address - Phone:541-673-4442
Mailing Address - Fax:541-673-1533
Practice Address - Street 1:1313 W HARVARD AVE
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-2838
Practice Address - Country:US
Practice Address - Phone:541-673-3355
Practice Address - Fax:541-673-1533
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR58361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice