Provider Demographics
NPI:1427113042
Name:MEDEL, MARK S (DDS ORAL AND MAXILLO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:MEDEL
Suffix:
Gender:M
Credentials:DDS ORAL AND MAXILLO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 N SHIAWASSEE ST
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867
Mailing Address - Country:US
Mailing Address - Phone:989-723-3882
Mailing Address - Fax:989-729-1723
Practice Address - Street 1:208 N SHIAWASSEE ST
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867
Practice Address - Country:US
Practice Address - Phone:989-723-3882
Practice Address - Fax:989-729-1723
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMM0137871223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Not Answered204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI9757860390OtherBCBSM
MI9757860390OtherBCBSM
MIOP14080Medicare ID - Type Unspecified