Healthcare Provider Details

I. General information

NPI: 1962481424
Provider Name (Legal Business Name): MARK LEE O'DELL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7971 MAIN ST
BIRCH RUN MI
48415-8001
US

IV. Provider business mailing address

9389 S BEYER RD
BIRCH RUN MI
48415-8426
US

V. Phone/Fax

Practice location:
  • Phone: 989-624-9381
  • Fax: 989-624-9353
Mailing address:
  • Phone: 989-624-6009
  • Fax: 989-624-9353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number11334
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: