Healthcare Provider Details

I. General information

NPI: 1861580532
Provider Name (Legal Business Name): L MARK MILDE DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 FIRST ST
MARBLE HILL MO
63764
US

IV. Provider business mailing address

PO BOX 650
MARBLE HILL MO
63764
US

V. Phone/Fax

Practice location:
  • Phone: 573-238-3330
  • Fax: 573-238-3464
Mailing address:
  • Phone: 573-238-3330
  • Fax: 573-238-3464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12724
License Number StateMO

VIII. Authorized Official

Name: DR. LOUIS MARK MILDE
Title or Position: DR L MARK MILDE DDS PRESIDENT
Credential: DDS
Phone: 573-238-3330