Basic Information
| Provider Information | |||||||||
| NPI: | 1801312145 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOUSTON | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | USA DENTAL HEALTH ACTIVITY | ||||||||
| Address2: | 652 HAMELTON ROAD | ||||||||
| City: | FORT SILL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804423905 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | USA DENTAL HEALTH ACTIVITY | ||||||||
| Address2: | 652 HAMELTON ROAD | ||||||||
| City: | FORT SILL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804423905 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 10418449-9921 | UT | Y | Dental Providers | Dentist |
No ID Information.