Provider Demographics
NPI:1265593107
Name:BAUMGARTNER, MARK HOWARD (DMD , MS)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:HOWARD
Last Name:BAUMGARTNER
Suffix:
Gender:M
Credentials:DMD , MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 W. MCMILLAN ST., PO BOX 929
Mailing Address - Street 2:
Mailing Address - City:MARSHFIED
Mailing Address - State:WI
Mailing Address - Zip Code:54449
Mailing Address - Country:US
Mailing Address - Phone:715-387-1702
Mailing Address - Fax:715-387-8174
Practice Address - Street 1:306 W. MCMILLAN ST.
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449
Practice Address - Country:US
Practice Address - Phone:715-387-1702
Practice Address - Fax:715-387-8174
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20050376231223G0001X
WI6211-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice