Healthcare Provider Details

I. General information

NPI: 1144280934
Provider Name (Legal Business Name): MARK DWAIN FENTON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 02/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8548 BEECHMONT AVE
CINCINNATI OH
45255-4708
US

IV. Provider business mailing address

375 INDIAN RIPPLE ROAD
WILMINGTON OH
45177
US

V. Phone/Fax

Practice location:
  • Phone: 513-474-0122
  • Fax: 513-474-1376
Mailing address:
  • Phone: 937-383-2410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4191
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: