Healthcare Provider Details

I. General information

NPI: 1700997327
Provider Name (Legal Business Name): MARK W BOBACK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 W 3RD AVE N
AURORA MN
55705
US

IV. Provider business mailing address

27 N ERIE ST
AURORA MN
55705
US

V. Phone/Fax

Practice location:
  • Phone: 218-229-3341
  • Fax:
Mailing address:
  • Phone: 218-229-2112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7982
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: