Healthcare Provider Details

I. General information

NPI: 1720045685
Provider Name (Legal Business Name): MARK RAY MCILWAIN DMD, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

398 ASHE BLVD
SHEFFIELD AL
35660-1729
US

IV. Provider business mailing address

398 ASHE BLVD
SHEFFIELD AL
35660-1729
US

V. Phone/Fax

Practice location:
  • Phone: 256-383-1499
  • Fax: 256-383-9135
Mailing address:
  • Phone: 256-383-1499
  • Fax: 256-383-9135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberLNO3783
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number00016147
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: