Healthcare Provider Details

I. General information

NPI: 1851480628
Provider Name (Legal Business Name): MARK ALAN RALPH DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E DIAMOND AVE
EVANSVILLE IN
47711-3714
US

IV. Provider business mailing address

2353 WHITESBURG DRIVE
HUNTSVILLE AL
35801
US

V. Phone/Fax

Practice location:
  • Phone: 812-461-2365
  • Fax: 812-461-2366
Mailing address:
  • Phone: 256-533-3735
  • Fax: 256-533-3780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number4813
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12012871A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: