Provider Demographics
NPI:1053003434
Name:BREINHOLT, MARK ROBERT (DDS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ROBERT
Last Name:BREINHOLT
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 1:104 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LYNDEN
Mailing Address - State:WA
Mailing Address - Zip Code:98264-1959
Mailing Address - Country:US
Mailing Address - Phone:360-354-0206
Mailing Address - Fax:
Practice Address - Street 1:104 6TH ST
Practice Address - Street 2:
Practice Address - City:LYNDEN
Practice Address - State:WA
Practice Address - Zip Code:98264-1959
Practice Address - Country:US
Practice Address - Phone:360-354-0206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADENT.DE.61445260122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist