Healthcare Provider Details

I. General information

NPI: 1831161777
Provider Name (Legal Business Name): MARK MICHAEL MALMBERG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 N 6TH ST
OAKES ND
58474-1214
US

IV. Provider business mailing address

19 N 6TH ST
OAKES ND
58474-1214
US

V. Phone/Fax

Practice location:
  • Phone: 701-742-3401
  • Fax:
Mailing address:
  • Phone: 701-742-3401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1650
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: