Healthcare Provider Details

I. General information

NPI: 1225035207
Provider Name (Legal Business Name): MARK W HAMM DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1313 W HARVARD AVE
ROSEBURG OR
97470-2838
US

IV. Provider business mailing address

1381 SE MAGNOLIA DR
ROSEBURG OR
97470-4373
US

V. Phone/Fax

Practice location:
  • Phone: 541-673-3355
  • Fax: 541-673-1533
Mailing address:
  • Phone: 541-673-4442
  • Fax: 541-673-1533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5836
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: