Healthcare Provider Details

I. General information

NPI: 1952469868
Provider Name (Legal Business Name): MARK R DRIVER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1651 NW HUGHWOOD CT
ROSEBURG OR
97471-8834
US

IV. Provider business mailing address

1651 NW HUGHWOOD CT
ROSEBURG OR
97471-8834
US

V. Phone/Fax

Practice location:
  • Phone: 541-672-8187
  • Fax: 541-672-0240
Mailing address:
  • Phone: 541-672-8187
  • Fax: 541-672-0240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5158
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: