Basic Information
| Provider Information | |||||||||
| NPI: | 1124278858 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SNOW | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | HAROLD | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OTHELLO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993440546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094885256 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2344 N MERRITT CREEK LOOP | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838144950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086768500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2008 | ||||||||
| LastUpdateDate: | 04/08/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 7078744-9922 | UT | N | Dental Providers | Dentist | General Practice | 1223G0001X | DE60035255 | WA | N | Dental Providers | Dentist | General Practice | 1223G0001X | 7620 | AZ | N | Dental Providers | Dentist | General Practice | 1223G0001X | D4194 | ID | Y | Dental Providers | Dentist | General Practice |
No ID Information.