Healthcare Provider Details

I. General information

NPI: 1114966405
Provider Name (Legal Business Name): MARK FIELDING STAPLETON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

498 HARLOW RD
SPRINGFIELD OR
97477-1336
US

IV. Provider business mailing address

498 HARLOW RD
SPRINGFIELD OR
97477-1336
US

V. Phone/Fax

Practice location:
  • Phone: 541-736-5525
  • Fax:
Mailing address:
  • Phone: 541-736-5525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD8570
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2116
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: