Provider Demographics
NPI:1588621338
Name:JURKOVICH, MARK W (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:JURKOVICH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29663 GATEWAY AVE
Mailing Address - Street 2:
Mailing Address - City:CHISAGO CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55013-0339
Mailing Address - Country:US
Mailing Address - Phone:651-257-3639
Mailing Address - Fax:651-257-6369
Practice Address - Street 1:29663 GATEWAY AVE
Practice Address - Street 2:
Practice Address - City:CHISAGO CITY
Practice Address - State:MN
Practice Address - Zip Code:55013-0339
Practice Address - Country:US
Practice Address - Phone:651-257-3639
Practice Address - Fax:651-257-6369
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8654M1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice