Healthcare Provider Details

I. General information

NPI: 1063604429
Provider Name (Legal Business Name): MARK T MCDONALD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2007
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3246 12TH AVE RD
NAMPA ID
83686-8404
US

IV. Provider business mailing address

3246 12TH AVE RD
NAMPA ID
83686-8404
US

V. Phone/Fax

Practice location:
  • Phone: 208-467-9690
  • Fax: 208-466-0412
Mailing address:
  • Phone: 208-467-9690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD3958
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: