Provider Demographics
NPI:1285623330
Name:MINCHOW, MARK ALAN (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
Last Name:MINCHOW
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 1:306 S 4TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SEWARD
Mailing Address - State:NE
Mailing Address - Zip Code:68434
Mailing Address - Country:US
Mailing Address - Phone:402-643-2931
Mailing Address - Fax:402-643-4258
Practice Address - Street 1:306 S 4TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SEWARD
Practice Address - State:NE
Practice Address - Zip Code:68434
Practice Address - Country:US
Practice Address - Phone:402-643-2931
Practice Address - Fax:402-643-4258
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE5918122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE098472SEMedicaid