Provider Demographics
NPI:1649360470
Name:SHERMAN, MARK THOMAS (DDS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
Last Name:SHERMAN
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:PO BOX 128
Mailing Address - Street 2:30957 OLD HWY 371
Mailing Address - City:PEQUOT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56472-0128
Mailing Address - Country:US
Mailing Address - Phone:218-568-8295
Mailing Address - Fax:218-568-4702
Practice Address - Street 1:30957 OLD HWY 371
Practice Address - Street 2:
Practice Address - City:PEQUOT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56472-0128
Practice Address - Country:US
Practice Address - Phone:218-568-8295
Practice Address - Fax:218-568-4702
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN110151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice