Provider Demographics
NPI:1790819050
Name:DALE, MARK M (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:M
Last Name:DALE
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6810 HEMLOCK LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-5502
Mailing Address - Country:US
Mailing Address - Phone:763-425-9888
Mailing Address - Fax:763-425-9835
Practice Address - Street 1:6810 HEMLOCK LN N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-5502
Practice Address - Country:US
Practice Address - Phone:763-425-9888
Practice Address - Fax:763-425-9835
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND103141223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics