MEDICARE: L MARK MILDE DDS PC

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	1223G0001X	General Practice Dentistry	12724	MO

General Provider Information

NPI Number	:	1861580532
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	L MARK MILDE DDS PC

Provider Business Mailing Address
First Line	:	PO BOX 650
Second Line	:
City	:	MARBLE HILL
State	:	MO
Zip	:	63764
Country	:	US
Telephone Number	:	573-238-3330
Fax Number	:	573-238-3464

Provider Business Practice Location Address
First Line	:	101 FIRST ST
Second Line	:
City	:	MARBLE HILL
State	:	MO
Zip	:	63764
Country	:	US
Telephone Number	:	573-238-3330
Fax Number	:	573-238-3464

Authorized Official
Title or Position	:	DR L MARK MILDE DDS PRESIDENT
Name	:	DR. LOUIS MARK MILDE
Credential	:	DDS
Telephone Number	:	573-238-3330

Provider Enumeration Date	:	10/10/2006
Last Update Date	:	08/22/2020

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