Healthcare Provider Details

I. General information

NPI: 1396959508
Provider Name (Legal Business Name): MARK D. JUNGDAHL DMD INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 SUMMITT SQ
MIDDLETOWN OH
45042-3464
US

IV. Provider business mailing address

1035 SUMMITT SQ
MIDDLETOWN OH
45042-3464
US

V. Phone/Fax

Practice location:
  • Phone: 513-424-5339
  • Fax: 513-422-1646
Mailing address:
  • Phone: 513-424-5339
  • Fax: 513-422-1646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number16076
License Number StateOH

VIII. Authorized Official

Name: SUSAN PATTERSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 513-424-5339