Provider Demographics
NPI:1669659108
Name:MARK D. MARKHAM, DDS, PLC.
Entity Type:Organization
Organization Name:MARK D. MARKHAM, DDS, PLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MARKHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:712-243-1833
Mailing Address - Street 1:1501 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC
Mailing Address - State:IA
Mailing Address - Zip Code:50022-1936
Mailing Address - Country:US
Mailing Address - Phone:712-243-1833
Mailing Address - Fax:712-243-7552
Practice Address - Street 1:1501 E 10TH ST
Practice Address - Street 2:
Practice Address - City:ATLANTIC
Practice Address - State:IA
Practice Address - Zip Code:50022-1936
Practice Address - Country:US
Practice Address - Phone:712-243-1833
Practice Address - Fax:712-243-7552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA64731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1163725Medicaid