Provider Demographics
NPI:1851480628
Name:RALPH, MARK ALAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
Last Name:RALPH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2353 WHITESBURG DRIVE
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801
Mailing Address - Country:US
Mailing Address - Phone:256-533-3735
Mailing Address - Fax:256-533-3780
Practice Address - Street 1:400 E DIAMOND AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47711-3714
Practice Address - Country:US
Practice Address - Phone:812-461-2365
Practice Address - Fax:812-461-2366
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4813122300000X
IN12012871A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL5151085OtherBLUE CROSS