Provider Demographics
NPI:1417082884
Name:PINKERTON, MARK D (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:PINKERTON
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:PO BOX 1127
Mailing Address - Street 2:
Mailing Address - City:WILBER
Mailing Address - State:NE
Mailing Address - Zip Code:68465
Mailing Address - Country:US
Mailing Address - Phone:402-821-2829
Mailing Address - Fax:402-821-2827
Practice Address - Street 1:114 W 3RD ST
Practice Address - Street 2:
Practice Address - City:WILBER
Practice Address - State:NE
Practice Address - Zip Code:68465
Practice Address - Country:US
Practice Address - Phone:402-821-2829
Practice Address - Fax:402-821-2827
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE54961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47076605000Medicaid