Provider Demographics
NPI:1851481329
Name:JUNGDAHL, MARK (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:JUNGDAHL
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 1:1035 SUMMITT SQ
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45042-3464
Mailing Address - Country:US
Mailing Address - Phone:513-424-5339
Mailing Address - Fax:513-422-1646
Practice Address - Street 1:1035 SUMMITT SQ
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45042-3464
Practice Address - Country:US
Practice Address - Phone:513-424-5339
Practice Address - Fax:513-422-1646
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH160761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice