Provider Demographics
NPI:1851445738
Name:MOLLNER, MARK DOUGLASS (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DOUGLASS
Last Name:MOLLNER
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 1:685 CITADEL DR E STE 313
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-5316
Mailing Address - Country:US
Mailing Address - Phone:719-574-1741
Mailing Address - Fax:719-596-6723
Practice Address - Street 1:685 CITADEL DR E STE 313
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5316
Practice Address - Country:US
Practice Address - Phone:719-574-1741
Practice Address - Fax:719-596-6723
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO59301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice