Healthcare Provider Details

I. General information

NPI: 1609070226
Provider Name (Legal Business Name): BENJAMIN F MACK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 01/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 7TH ST NE
DEVILS LAKE ND
58301-2719
US

IV. Provider business mailing address

1003 7TH ST NE
DEVILS LAKE ND
58301-2719
US

V. Phone/Fax

Practice location:
  • Phone: 701-662-8191
  • Fax: 701-662-5757
Mailing address:
  • Phone: 701-662-8191
  • Fax: 701-662-5757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2011
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: