Provider Demographics
NPI:1598951055
Name:MARK S MEDEL DDS PC
Entity Type:Organization
Organization Name:MARK S MEDEL DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:MEDEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS ORAL AND MAXILLO
Authorized Official - Phone:989-723-3882
Mailing Address - Street 1:208 N SHIAWASSEE ST
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48831
Mailing Address - Country:US
Mailing Address - Phone:989-723-3882
Mailing Address - Fax:989-729-1723
Practice Address - Street 1:208 N SHIAWASSEE ST
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48831
Practice Address - Country:US
Practice Address - Phone:989-723-3882
Practice Address - Fax:989-729-1723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMM137871223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI9757860390OtherBCBS
OP14080Medicare PIN