MEDICARE: DR. MARK W JURKOVICH DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	8654M	MN

General Provider Information

NPI Number	:	1588621338
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK W JURKOVICH DDS

Provider Business Mailing Address
First Line	:	29663 GATEWAY AVE
Second Line	:
City	:	CHISAGO CITY
State	:	MN
Zip	:	55013-0339
Country	:	US
Telephone Number	:	651-257-3639
Fax Number	:	651-257-6369

Provider Business Practice Location Address
First Line	:	29663 GATEWAY AVE
Second Line	:
City	:	CHISAGO CITY
State	:	MN
Zip	:	55013-0339
Country	:	US
Telephone Number	:	651-257-3639
Fax Number	:	651-257-6369

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/26/2006
Last Update Date	:	07/08/2007

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