Provider Demographics
NPI:1619954203
Name:GILMORE, MARK LYNN (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:LYNN
Last Name:GILMORE
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 1:415 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3111
Mailing Address - Country:US
Mailing Address - Phone:719-546-3333
Mailing Address - Fax:719-546-3334
Practice Address - Street 1:4655 STATE AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66102-3603
Practice Address - Country:US
Practice Address - Phone:913-278-7977
Practice Address - Fax:913-278-5022
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS602741223G0001X
MO20040149201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice