Provider Demographics
NPI:1013281302
Name:LEGAN, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LEGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:
Other - Last Name:LEGAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1004 GLEN PAUL CT
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-8113
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1004 GLEN PAUL CT
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-8113
Practice Address - Country:US
Practice Address - Phone:651-490-1158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-04
Last Update Date:2012-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND89311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice