Provider Demographics
NPI:1700899135
Name:POWELL, MARK LAMARR (DDS MSD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:LAMARR
Last Name:POWELL
Suffix:
Gender:M
Credentials:DDS MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2076 BALDWIN DR
Mailing Address - Street 2:
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49428
Mailing Address - Country:US
Mailing Address - Phone:616-457-5866
Mailing Address - Fax:616-457-2195
Practice Address - Street 1:2076 BALDWIN DR
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428
Practice Address - Country:US
Practice Address - Phone:616-457-5866
Practice Address - Fax:616-457-2195
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010146361223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics