Provider Demographics
NPI:1962481424
Name:O'DELL, MARK LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LEE
Last Name:O'DELL
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 1:9389 S BEYER RD
Mailing Address - Street 2:
Mailing Address - City:BIRCH RUN
Mailing Address - State:MI
Mailing Address - Zip Code:48415-8426
Mailing Address - Country:US
Mailing Address - Phone:989-624-6009
Mailing Address - Fax:989-624-9353
Practice Address - Street 1:7971 MAIN ST
Practice Address - Street 2:
Practice Address - City:BIRCH RUN
Practice Address - State:MI
Practice Address - Zip Code:48415-8001
Practice Address - Country:US
Practice Address - Phone:989-624-9381
Practice Address - Fax:989-624-9353
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI11334122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI479934OtherUNITED CONCORDIA
MIJ113340OtherBC/BS OF MI
MI2926589Medicaid