Provider Demographics
NPI:1134113657
Name:VANZANT, MARK ALLEN (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:VANZANT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 BUSINESS CENTER LOOP STE C
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-6885
Mailing Address - Country:US
Mailing Address - Phone:406-752-4545
Mailing Address - Fax:406-752-4405
Practice Address - Street 1:203 BUSINESS CENTER LOOP STE C
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-6885
Practice Address - Country:US
Practice Address - Phone:406-752-4545
Practice Address - Fax:406-752-4405
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9527884-9922122300000X
MTDEN-DEN-LIC-115041223G0001X
FLDN 168681223G0001X
MT11504122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice