Provider Demographics
NPI:1811040868
Name:MORK, THOMAS OGDEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:OGDEN
Last Name:MORK
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 1:1119 N BREENS BAY RD
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-8724
Mailing Address - Country:US
Mailing Address - Phone:262-646-2748
Mailing Address - Fax:262-567-8496
Practice Address - Street 1:1259 CORPORATE CENTER DR
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4836
Practice Address - Country:US
Practice Address - Phone:262-567-7840
Practice Address - Fax:262-567-8496
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2680-0151223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics