Provider Demographics
NPI:1063604429
Name:MCDONALD, MARK T (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:T
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3246 12TH AVE RD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-8404
Mailing Address - Country:US
Mailing Address - Phone:208-467-9690
Mailing Address - Fax:
Practice Address - Street 1:3246 12TH AVE RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-8404
Practice Address - Country:US
Practice Address - Phone:208-467-9690
Practice Address - Fax:208-466-0412
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3958122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807650200Medicaid