Provider Demographics
NPI:1427792423
Name:SCHMIDT, MARK (DT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SCHMIDT
Suffix:
Gender:M
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 36
Mailing Address - Street 2:
Mailing Address - City:ALBERT LEA
Mailing Address - State:MN
Mailing Address - Zip Code:56007-0036
Mailing Address - Country:US
Mailing Address - Phone:507-377-5033
Mailing Address - Fax:
Practice Address - Street 1:141 E WILLIAM ST
Practice Address - Street 2:
Practice Address - City:ALBERT LEA
Practice Address - State:MN
Practice Address - Zip Code:56007-2530
Practice Address - Country:US
Practice Address - Phone:507-377-5033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDT123125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist