Healthcare Provider Details

I. General information

NPI: 1114957727
Provider Name (Legal Business Name): MARK EDWARD DYBALL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 06/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

861 HEALTH PARK BLVD
GRAND BLANC MI
48439
US

IV. Provider business mailing address

861 HEALTH PARK BLVD
GRAND BLANC MI
48439-7383
US

V. Phone/Fax

Practice location:
  • Phone: 810-953-0500
  • Fax: 810-953-0031
Mailing address:
  • Phone: 810-953-0500
  • Fax: 810-953-0031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number5101009577
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: