Provider Demographics
NPI:1740397611
Name:MARK L OHLSEN
Entity type:Organization
Organization Name:MARK L OHLSEN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:OHLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-334-7471
Mailing Address - Street 1:505 4TH ST NW
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021
Mailing Address - Country:US
Mailing Address - Phone:507-334-7471
Mailing Address - Fax:507-334-9736
Practice Address - Street 1:505 4TH ST NW
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021
Practice Address - Country:US
Practice Address - Phone:507-334-7471
Practice Address - Fax:507-334-9736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND 10296122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
273522900OtherMA