Provider Demographics
NPI:1366500142
Name:BALENSEIFEN, MARK WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILLIAM
Last Name:BALENSEIFEN
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 1:415 E MAIN ST STE 4
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-2259
Mailing Address - Country:US
Mailing Address - Phone:405-467-4092
Mailing Address - Fax:
Practice Address - Street 1:415 E MAIN ST STE 4
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-2259
Practice Address - Country:US
Practice Address - Phone:405-467-4092
Practice Address - Fax:405-467-4429
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK52101223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics