Provider Demographics
NPI:1275668899
Name:DUNHAM, MARK C (BS, IDC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:C
Last Name:DUNHAM
Suffix:
Gender:M
Credentials:BS, IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2045 E RIVER RD
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-8220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:COMDESRON FIFTEEN
Practice Address - Street 2:PSC 473 BOX 108
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96349
Practice Address - Country:US
Practice Address - Phone:513-277-0096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman