Provider Demographics
NPI:1932187093
Name:WOODDY, MARK WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILLIAM
Last Name:WOODDY
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 1:4600 W 89TH ST
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE VILLAGE
Mailing Address - State:KS
Mailing Address - Zip Code:66207-2251
Mailing Address - Country:US
Mailing Address - Phone:913-642-8811
Mailing Address - Fax:913-642-8813
Practice Address - Street 1:4600 W 89TH ST
Practice Address - Street 2:
Practice Address - City:PRAIRIE VILLAGE
Practice Address - State:KS
Practice Address - Zip Code:66207-2251
Practice Address - Country:US
Practice Address - Phone:913-642-8811
Practice Address - Fax:913-642-8813
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-08
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS60010122300000X, 1223G0001X
MO2000150743122300000X
VA410236122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist