Provider Demographics
NPI:1710061940
Name:HOUSE, MARK T (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:T
Last Name:HOUSE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:348 TEJON LN
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007
Mailing Address - Country:US
Mailing Address - Phone:719-647-1122
Mailing Address - Fax:719-647-1142
Practice Address - Street 1:318 ORCHARD SPRINGS DR
Practice Address - Street 2:
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007
Practice Address - Country:US
Practice Address - Phone:719-647-1122
Practice Address - Fax:719-647-1142
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1062751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO88834042Medicaid