Healthcare Provider Details

I. General information

NPI: 1497725162
Provider Name (Legal Business Name): MARK RICHARD OBLAD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 02/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14155 N 83RD AVE STE 141
PEORIA AZ
85381-5652
US

IV. Provider business mailing address

14155 N 83RD AVE STE 141
PEORIA AZ
85381-5652
US

V. Phone/Fax

Practice location:
  • Phone: 623-878-1000
  • Fax: 623-878-1024
Mailing address:
  • Phone: 623-878-1000
  • Fax: 623-878-1024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number4943072-9921
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number7744
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: