Provider Demographics
NPI:1780802975
Name:HOBERT L. MACK, D.D.S., INC
Entity type:Organization
Organization Name:HOBERT L. MACK, D.D.S., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:L
Authorized Official - Last Name:FLEMING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-752-3563
Mailing Address - Street 1:505 STRATTON ST
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-3806
Mailing Address - Country:US
Mailing Address - Phone:304-752-3563
Mailing Address - Fax:304-752-3148
Practice Address - Street 1:505 STRATTON ST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-3806
Practice Address - Country:US
Practice Address - Phone:304-752-3563
Practice Address - Fax:304-752-3148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810006947Medicaid