Provider Demographics
NPI:1346392453
Name:MARK E STOTZ DDS A PROFESSIONAL LLC
Entity type:Organization
Organization Name:MARK E STOTZ DDS A PROFESSIONAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:STOTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-342-1432
Mailing Address - Street 1:2525 W MAIN ST STE 304
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-2487
Mailing Address - Country:US
Mailing Address - Phone:605-342-1432
Mailing Address - Fax:605-342-8131
Practice Address - Street 1:2525 W MAIN ST STE 304
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-2487
Practice Address - Country:US
Practice Address - Phone:605-342-1432
Practice Address - Fax:605-342-8131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM6721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty