MEDICARE: MARK M INGRAM DMD

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	9355	GA

General Provider Information

NPI Number	:	1982758223
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK M INGRAM DMD

Provider Business Mailing Address
First Line	:	1407 E UNION ST
Second Line	:
City	:	VIENNA
State	:	GA
Zip	:	31092-7531
Country	:	US
Telephone Number	:	229-268-6079
Fax Number	:

Provider Business Practice Location Address
First Line	:	1407 E UNION ST
Second Line	:
City	:	VIENNA
State	:	GA
Zip	:	31092-7531
Country	:	US
Telephone Number	:	229-268-6079
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2007
Last Update Date	:	07/08/2007

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Directions to “ MARK M INGRAM DMD” Practice Location

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