=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760485965
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK IRIWN KAMPFE DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2005
-----------------------------------------------------
Last Update Date | 08/05/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2900 DOOLITTLE DR BLDG 6000 RM 1TB03 ELLSWORTH AFB
-----------------------------------------------------
City | ELLSWORTH AFB
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57706-4821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-385-3560
-----------------------------------------------------
Fax | 605-385-3498
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2900 DOOLITTLE DR BLDG 6000 RM 1TB03 ELLSWORTH AFB
-----------------------------------------------------
City | ELLSWORTH AFB
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57706-4821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-385-3560
-----------------------------------------------------
Fax | 605-385-3498
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 6481
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 5399
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------
=====================================================
Legacy Identifiers
=====================================================
Identifier #1
-----------------------------------------------------
Identifier Code | 6481
-----------------------------------------------------
Identifier Type | OTHER
-----------------------------------------------------
Identifier State | IA
-----------------------------------------------------
Identifier Issuer | DDS LICENSE NUMBER
-----------------------------------------------------
Identifier #2
-----------------------------------------------------
Identifier Code | 5399
-----------------------------------------------------
Identifier Type | OTHER
-----------------------------------------------------
Identifier State | NE
-----------------------------------------------------
Identifier Issuer | DDS LICENSE NUMBER
-----------------------------------------------------
=====================================================
Proprietary Identifiers Ever Reported
=====================================================
Identifier #1
-----------------------------------------------------
Identifier Code | 5399
-----------------------------------------------------
Identifier Type | OTHER
-----------------------------------------------------
Identifier State | NE
-----------------------------------------------------
Identifier Issuer | DDS LICENSE NUMBER
-----------------------------------------------------
Identifier #2
-----------------------------------------------------
Identifier Code | 6481
-----------------------------------------------------
Identifier Type | OTHER
-----------------------------------------------------
Identifier State | IA
-----------------------------------------------------
Identifier Issuer | DDS LICENSE NUMBER
-----------------------------------------------------