Provider Demographics
NPI:1508083528
Name:MORK, DESIREE MICHELE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DESIREE
Middle Name:MICHELE
Last Name:MORK
Suffix:
Gender:F
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:P.O. BOX 118
Mailing Address - Street 2:241 N. MAIN STREET
Mailing Address - City:COCHRANE
Mailing Address - State:WI
Mailing Address - Zip Code:54622
Mailing Address - Country:US
Mailing Address - Phone:608-248-2442
Mailing Address - Fax:608-248-3132
Practice Address - Street 1:241 N. MAIN STREET
Practice Address - Street 2:
Practice Address - City:COCHRANE
Practice Address - State:WI
Practice Address - Zip Code:54622
Practice Address - Country:US
Practice Address - Phone:608-248-2442
Practice Address - Fax:608-248-3132
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5882-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice