Healthcare Provider Details

I. General information

NPI: 1265580914
Provider Name (Legal Business Name): MARK JEREL RINGDAHL D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

320 5TH ST., PO#69
FREDERICK CO
80530
US

IV. Provider business mailing address

320 5TH STREET, PO #69
FREDERICK CO
80530
US

V. Phone/Fax

Practice location:
  • Phone: 303-833-3230
  • Fax:
Mailing address:
  • Phone: 303-833-3230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number105639
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: