Provider Demographics
NPI:1063928653
Name:MARK E. LOVE DMD ,PC
Entity type:Organization
Organization Name:MARK E. LOVE DMD ,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:LOVE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:256-332-6073
Mailing Address - Street 1:510 ENGLE DR SE
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35653-2749
Mailing Address - Country:US
Mailing Address - Phone:256-332-6073
Mailing Address - Fax:256-332-6655
Practice Address - Street 1:510 ENGLE DR SE
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35653-2749
Practice Address - Country:US
Practice Address - Phone:256-332-6073
Practice Address - Fax:256-332-6655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-19
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3951261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL63-11104550Medicaid