Provider Demographics
NPI:1538315460
Name:DAMRON, MARK D (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:DAMRON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 PEOPLES ST STE 90
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-4158
Mailing Address - Country:US
Mailing Address - Phone:423-928-0345
Mailing Address - Fax:423-926-4358
Practice Address - Street 1:2800 PEOPLES ST STE 90
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-4158
Practice Address - Country:US
Practice Address - Phone:423-928-0345
Practice Address - Fax:423-926-4358
Is Sole Proprietor?:No
Enumeration Date:2008-08-12
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY88181223G0001X
VA04014121831223G0001X
TNDS00000098381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100104540Medicaid