Provider Demographics
NPI:1912677709
Name:DRINKWINE, MARK A
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:DRINKWINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8139 COMOX LOOP
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:WA
Mailing Address - Zip Code:98230-9320
Mailing Address - Country:US
Mailing Address - Phone:360-927-3688
Mailing Address - Fax:
Practice Address - Street 1:157 LOPEZ RD.
Practice Address - Street 2:
Practice Address - City:LOPEZ ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98261
Practice Address - Country:US
Practice Address - Phone:360-468-2551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH00005848124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist