Provider Demographics
NPI:1750450623
Name:WHEELER, MARK STEVEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:STEVEN
Last Name:WHEELER
Suffix:
Gender:M
Credentials:DMD
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Mailing Address - Street 1:1300 SOUTHTOWN BLVD
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-7481
Mailing Address - Country:US
Mailing Address - Phone:270-684-9256
Mailing Address - Fax:270-926-0016
Practice Address - Street 1:1300 SOUTHTOWN BLVD
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-7481
Practice Address - Country:US
Practice Address - Phone:270-684-9256
Practice Address - Fax:270-926-0016
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY60361223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYU21274Medicare UPIN