JEFFREY D DOMARK DMD Dentist License verification

Business Entity

NOT RENEWED

License Type

Dentist

Description

LICENSED DENTIST CONTROLLED SUBSTANCE

License Number

31*****00

License Status

NOT RENEWED

Business

First Name

JEFFREY

Middle

Last Name

DOMARK

Suffix

DMD

Business Name

JEFFREY D DOMARK DMD

Original Issue Date

05/06/2009

Effective Date

05/06/2009

Expiration Date

09/30/2009

City

GLEN CARBON

State

Zip

62034

County

MADISON

Specialty/Qualifier

PRACTITIONER

Controlled Substance Schedule

II III IV V

Ever Disciplined

LastModifiedDate

11/04/2009