Healthcare Provider Details

I. General information

NPI: 1902029333
Provider Name (Legal Business Name): MARK I ENSMAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2516 W 15TH AVE
EMPORIA KS
66801-6102
US

IV. Provider business mailing address

PO BOX 1154
EMPORIA KS
66801-1154
US

V. Phone/Fax

Practice location:
  • Phone: 620-342-8032
  • Fax: 620-342-5735
Mailing address:
  • Phone: 620-342-8032
  • Fax: 620-342-5735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5429
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: