MEDICARE: DR. MARK CARLYLE WOODBURY DMD

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	1223P0221X	Pediatric Dentistry	DEN.00206270	CO

General Provider Information

NPI Number	:	1619663051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK CARLYLE WOODBURY DMD

Provider Business Mailing Address
First Line	:	8276 MOSBY WAY
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80908-5692
Country	:	US
Telephone Number	:	801-712-7403
Fax Number	:

Provider Business Practice Location Address
First Line	:	6620 CAMDEN BLVD
Second Line	:
City	:	FOUNTAIN
State	:	CO
Zip	:	80817-2505
Country	:	US
Telephone Number	:	719-631-6136
Fax Number	:

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

Provider Enumeration Date	:	04/17/2023
Last Update Date	:	08/13/2025

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