Provider Demographics
NPI:1568623585
Name:CHAMBERS, MARK E
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:CHAMBERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 SCHNEIDER AVE SE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-2820
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3101 SCHNEIDER AVE SE
Practice Address - Street 2:SUITE 1
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-2820
Practice Address - Country:US
Practice Address - Phone:715-233-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6233-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice