Provider Demographics
NPI:1770860157
Name:MARK, MARY (RDH)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:MARK
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 FAIRGROUNDS RD
Mailing Address - Street 2:
Mailing Address - City:TWO HARBORS
Mailing Address - State:MN
Mailing Address - Zip Code:55616-4600
Mailing Address - Country:US
Mailing Address - Phone:218-206-4327
Mailing Address - Fax:
Practice Address - Street 1:1313 FAIRGROUNDS ROAD
Practice Address - Street 2:PO BOX 146
Practice Address - City:TWO HARBORS
Practice Address - State:MN
Practice Address - Zip Code:55616-3000
Practice Address - Country:US
Practice Address - Phone:218-206-4327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN04720124Q00000X
WI5398016124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist