Provider Demographics
NPI:1952469868
Name:DRIVER, MARK R (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:DRIVER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1651 NW HUGHWOOD CT
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-8834
Mailing Address - Country:US
Mailing Address - Phone:541-672-8187
Mailing Address - Fax:541-672-0240
Practice Address - Street 1:1651 NW HUGHWOOD CT
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-8834
Practice Address - Country:US
Practice Address - Phone:541-672-8187
Practice Address - Fax:541-672-0240
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR51581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice