Provider Demographics
NPI:1154493724
Name:MCDANIELS, MARK KENNETH (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:KENNETH
Last Name:MCDANIELS
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 1:350 S 38TH CT STE 225
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-5775
Mailing Address - Country:US
Mailing Address - Phone:425-271-1515
Mailing Address - Fax:425-228-4146
Practice Address - Street 1:350 S 38TH CT STE 225
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5775
Practice Address - Country:US
Practice Address - Phone:425-271-1515
Practice Address - Fax:425-228-4146
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000060521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAK439D7Medicaid
WADE00006052OtherWA STATE DEPT OF HEALTH