Provider Demographics
NPI:1336406800
Name:DEROCHER, MARK JOEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOEL
Last Name:DEROCHER
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 1:45 WASHINGTON AVE E
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:MN
Mailing Address - Zip Code:55350-2574
Mailing Address - Country:US
Mailing Address - Phone:952-649-7255
Mailing Address - Fax:
Practice Address - Street 1:45 WASHINGTON AVE E
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:MN
Practice Address - Zip Code:55350-2574
Practice Address - Country:US
Practice Address - Phone:320-587-3502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-20
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND131281223X0400X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist