Provider Demographics
NPI:1730107491
Name:HENLINE, MARK H (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:H
Last Name:HENLINE
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 1:350 PINE ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-1669
Mailing Address - Country:US
Mailing Address - Phone:605-721-8939
Mailing Address - Fax:605-721-8998
Practice Address - Street 1:350 PINE ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-1669
Practice Address - Country:US
Practice Address - Phone:605-721-8939
Practice Address - Fax:605-721-8998
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0175131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0542952Medicaid