=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396959508
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK D. JUNGDAHL DMD INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1035 SUMMITT SQ
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45042-3464
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-424-5339
-----------------------------------------------------
Fax | 513-422-1646
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1035 SUMMITT SQ
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45042-3464
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-424-5339
-----------------------------------------------------
Fax | 513-422-1646
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | SUSAN PATTERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 513-424-5339
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 16076
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------