Provider Demographics
NPI:1497030100
Name:FOSTER, MARK DALE (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DALE
Last Name:FOSTER
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4302 CANVASBACK LN
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-9146
Mailing Address - Country:US
Mailing Address - Phone:414-581-3222
Mailing Address - Fax:
Practice Address - Street 1:413 N 17TH AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4226
Practice Address - Country:US
Practice Address - Phone:715-842-4649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-13
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6740-151223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics