Healthcare Provider Details

I. General information

NPI: 1235589961
Provider Name (Legal Business Name): MARK KINGSTON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2016
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
MORGANTOWN WV
26506
US

IV. Provider business mailing address

PO BOX 9400
MORGANTOWN WV
26506-9400
US

V. Phone/Fax

Practice location:
  • Phone: 304-293-5251
  • Fax:
Mailing address:
  • Phone: 304-293-5251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2017002808
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: