Provider Demographics
NPI:1780750703
Name:MARK A KNOLLMAN DDS PA
Entity type:Organization
Organization Name:MARK A KNOLLMAN DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-254-5677
Mailing Address - Street 1:600 B CENTREPARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28805
Mailing Address - Country:US
Mailing Address - Phone:828-254-5677
Mailing Address - Fax:828-254-1468
Practice Address - Street 1:600 B CENTREPARK DRIVE
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28805
Practice Address - Country:US
Practice Address - Phone:828-254-5677
Practice Address - Fax:828-254-1468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5720122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8995064Medicaid