Provider Demographics
NPI:1689765984
Name:MACK, STEVEN J (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:J
Last Name:MACK
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1906 MIDDLE ROAD
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722
Mailing Address - Country:US
Mailing Address - Phone:563-359-4686
Mailing Address - Fax:563-359-4696
Practice Address - Street 1:1906 MIDDLE ROAD
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722
Practice Address - Country:US
Practice Address - Phone:563-359-4686
Practice Address - Fax:563-359-4696
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAO77851223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics