JEFFREY D DOMARK DMD Dentist License verification

Business Entity

NOT RENEWED

License Type

Dentist

Description

LICENSED DENTIST CONTROLLED SUBSTANCE

License Number

31*****76

License Status

NOT RENEWED

Business

First Name

JEFFREY

Middle

Last Name

DOMARK

Suffix

DMD

Business Name

JEFFREY D DOMARK DMD

Original Issue Date

08/26/2009

Effective Date

08/26/2009

Expiration Date

09/30/2012

City

ALTON

State

Zip

62002

County

MADISON

Specialty/Qualifier

PRACTITIONER

Controlled Substance Schedule

II III IV V

Ever Disciplined

LastModifiedDate

11/14/2012