Provider Demographics
NPI:1528100765
Name:WESTPHAL, MARK ALLEN (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLEN
Last Name:WESTPHAL
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 1:213 W 38TH ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-4626
Mailing Address - Country:US
Mailing Address - Phone:308-635-3232
Mailing Address - Fax:308-635-2968
Practice Address - Street 1:213 W 38TH ST
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4626
Practice Address - Country:US
Practice Address - Phone:308-635-3232
Practice Address - Fax:308-635-2968
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE5166122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47-0658545-01Medicaid