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General NPI Number Information
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NPI Number | 1265654107
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Entity Type | Individual
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Provider Name | JOHN MARK EATON D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 05/02/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 107 WARREN ST STE 1
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City | BEAVER DAM
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State | WI
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Zip | 53916-3031
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Country | US
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Telephone | 920-887-7667
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Fax |
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Provider Business Mailing Address
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Address Line | 6836 STARBURST DR
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City | SUN PRAIRIE
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State | WI
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Zip | 53590-9119
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Country | US
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Telephone | 608-837-8329
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 4525-015
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License Number State | WI
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