MEDICARE: MORK DENTAL, SC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	5882015	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457507329
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MORK DENTAL, SC

Provider Business Mailing Address
First Line	:	34 N MAIN ST
Second Line	:	PO BOX 367
City	:	FOUNTAIN CITY
State	:	WI
Zip	:	54629-8705
Country	:	US
Telephone Number	:	608-687-3571
Fax Number	:

Provider Business Practice Location Address
First Line	:	34 N MAIN ST
Second Line	:
City	:	FOUNTAIN CITY
State	:	WI
Zip	:	54629-8705
Country	:	US
Telephone Number	:	608-687-3571
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DESIREE M. MORK
Credential	:	D.D.S.
Telephone Number	:	608-687-3571

Provider Enumeration Date	:	08/12/2008
Last Update Date	:	08/12/2008

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Directions to “MORK DENTAL, SC ” Practice Location

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