Provider Demographics
NPI:1124343025
Name:MORK DENTAL, SC
Entity type:Organization
Organization Name:MORK DENTAL, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DESIREE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MORK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-687-3571
Mailing Address - Street 1:PO BOX 367
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN CITY
Mailing Address - State:WI
Mailing Address - Zip Code:54629-0367
Mailing Address - Country:US
Mailing Address - Phone:608-687-3571
Mailing Address - Fax:608-687-6007
Practice Address - Street 1:241 N. MAIN ST.
Practice Address - Street 2:
Practice Address - City:COCHRANE
Practice Address - State:WI
Practice Address - Zip Code:54622
Practice Address - Country:US
Practice Address - Phone:608-248-2442
Practice Address - Fax:608-248-3132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-02
Last Update Date:2010-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI62840151223G0001X
WI58820151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty