1861580532 NPI number — L MARK MILDE DDS PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861580532 NPI number — L MARK MILDE DDS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
L MARK MILDE DDS PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861580532
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 FIRST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARBLE HILL
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63764
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-238-3330
Provider Business Practice Location Address Fax Number:
573-238-3464
Provider Enumeration Date:
10/10/2006

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  12724 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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