Provider Demographics
NPI:1700997327
Name:BOBACK, MARK W (DDS)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:W
Last Name:BOBACK
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 1:27 N ERIE ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:MN
Mailing Address - Zip Code:55705
Mailing Address - Country:US
Mailing Address - Phone:218-229-2112
Mailing Address - Fax:
Practice Address - Street 1:22 W 3RD AVE N
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:MN
Practice Address - Zip Code:55705
Practice Address - Country:US
Practice Address - Phone:218-229-3341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7982122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6175382OtherMNCARE #