Provider Demographics
NPI:1508603200
Name:OVERBY, MARA INGRID
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:INGRID
Last Name:OVERBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 8TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:MN
Mailing Address - Zip Code:55912-2028
Mailing Address - Country:US
Mailing Address - Phone:507-279-2185
Mailing Address - Fax:
Practice Address - Street 1:13899 HIGHWAY 13 SOUTH FRONTAGE ROAD
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378
Practice Address - Country:US
Practice Address - Phone:952-440-2935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND15142122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist