Healthcare Provider Details

I. General information

NPI: 1417610668
Provider Name (Legal Business Name): KEVIN JEFFREY MARK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2021
Last Update Date: 10/14/2021
Certification Date: 10/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 6TH AVE SW
BOWMAN ND
58623-4518
US

IV. Provider business mailing address

12 6TH AVE SW BOX 710
BOWMAN ND
58623
US

V. Phone/Fax

Practice location:
  • Phone: 701-523-3255
  • Fax:
Mailing address:
  • Phone: 701-523-3255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2442
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: