Provider Demographics
NPI:1396720231
Name:DITTMER, MARK A (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:DITTMER
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 1:51300 POMERANTZ FAMILY PAVILION
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242
Mailing Address - Country:US
Mailing Address - Phone:319-356-2743
Mailing Address - Fax:319-353-6923
Practice Address - Street 1:51300 POMERANTZ FAMILY PAVILION
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52240
Practice Address - Country:US
Practice Address - Phone:319-356-2743
Practice Address - Fax:319-353-6923
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA071411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0248039Medicaid
IA24803Medicare ID - Type Unspecified
T01415Medicare UPIN