Provider Demographics
NPI:1467628222
Name:MARK G. WOMACK, DDS, INC.
Entity Type:Organization
Organization Name:MARK G. WOMACK, DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:G
Authorized Official - Last Name:WOMACK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:530-345-7127
Mailing Address - Street 1:952 LUPIN AVE
Mailing Address - Street 2:SUITE #110
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95973-0933
Mailing Address - Country:US
Mailing Address - Phone:530-345-7127
Mailing Address - Fax:530-345-4914
Practice Address - Street 1:952 LUPIN AVE
Practice Address - Street 2:SUITE #110
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95973-0933
Practice Address - Country:US
Practice Address - Phone:530-345-7127
Practice Address - Fax:530-345-4914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD370371223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty