Healthcare Provider Details

I. General information

NPI: 1568440980
Provider Name (Legal Business Name): MARK LEONARD GONSEWSKI D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 E BROAD ST
EUFAULA AL
36027-2023
US

IV. Provider business mailing address

131 E BROAD ST
EUFAULA AL
36027-2023
US

V. Phone/Fax

Practice location:
  • Phone: 334-687-3752
  • Fax: 334-687-3802
Mailing address:
  • Phone: 334-687-3752
  • Fax: 334-687-3802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4228
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: