Healthcare Provider Details

I. General information

NPI: 1780802975
Provider Name (Legal Business Name): HOBERT L. MACK, D.D.S., INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 STRATTON ST
LOGAN WV
25601-3806
US

IV. Provider business mailing address

505 STRATTON ST
LOGAN WV
25601-3806
US

V. Phone/Fax

Practice location:
  • Phone: 304-752-3563
  • Fax: 304-752-3148
Mailing address:
  • Phone: 304-752-3563
  • Fax: 304-752-3148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2429
License Number StateWV

VIII. Authorized Official

Name: MRS. KRISTINA L FLEMING
Title or Position: SECRETARY
Credential:
Phone: 304-752-3563