Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | D1014 | SD |
NPI | 1114225661 |
---|---|
Provider Name | Dr. Mark Allen Terry |
First Address | Rapid City, SD 57702-3477 |
Second Address | Rapid City, SD 57702-3477 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/03/2011 |
Last Update Date | 24/06/2016 |