Healthcare Provider Details

I. General information

NPI: 1649258666
Provider Name (Legal Business Name): MARK ALLEN WHEELER D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

899 HIGHWAY 287 SUITE 100
BROOMFIELD CO
80020-7000
US

IV. Provider business mailing address

2461 RANCH RESERVE RDG
WESTMINSTER CO
80234-2693
US

V. Phone/Fax

Practice location:
  • Phone: 303-469-6375
  • Fax: 303-465-0656
Mailing address:
  • Phone: 303-870-9151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number6119
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: