Provider Demographics
NPI:1417515255
Name:ROSENTHALL, MARK REX (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:REX
Last Name:ROSENTHALL
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 N WHEELING AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-1769
Mailing Address - Country:US
Mailing Address - Phone:765-289-2377
Mailing Address - Fax:765-289-3909
Practice Address - Street 1:3901 N WHEELING AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-1769
Practice Address - Country:US
Practice Address - Phone:765-289-2377
Practice Address - Fax:765-289-3909
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120100651223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics