Provider Demographics
NPI:1215267976
Name:MILDE, L. MARK (DDS)
Entity type:Individual
Prefix:
First Name:L.
Middle Name:MARK
Last Name:MILDE
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 1:101 FIRST ST
Mailing Address - Street 2:
Mailing Address - City:MARBLE HILL
Mailing Address - State:MO
Mailing Address - Zip Code:63764
Mailing Address - Country:US
Mailing Address - Phone:573-238-3330
Mailing Address - Fax:573-238-3464
Practice Address - Street 1:101 FIRST ST.
Practice Address - Street 2:
Practice Address - City:MARBLE HILL
Practice Address - State:MO
Practice Address - Zip Code:63764
Practice Address - Country:US
Practice Address - Phone:573-238-3330
Practice Address - Fax:573-238-3464
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-31
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO127241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice