Provider Demographics
NPI:1700994571
Name:MIEDEMA, MARK (DDS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MIEDEMA
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 1:37 NORTHWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WEST BATH
Mailing Address - State:ME
Mailing Address - Zip Code:04530-6625
Mailing Address - Country:US
Mailing Address - Phone:207-442-9706
Mailing Address - Fax:
Practice Address - Street 1:TOGUS VA HOSPITAL
Practice Address - Street 2:1 VA CENTER
Practice Address - City:TOGUS
Practice Address - State:ME
Practice Address - Zip Code:04330
Practice Address - Country:US
Practice Address - Phone:207-623-8411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME35351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice