Provider Demographics
NPI:1164513685
Name:ETHRIDGE, MARK LANCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LANCE
Last Name:ETHRIDGE
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 1:1101 N JUPITER RD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-3171
Mailing Address - Country:US
Mailing Address - Phone:972-669-9060
Mailing Address - Fax:972-669-4108
Practice Address - Street 1:1101 N JUPITER RD
Practice Address - Street 2:SUITE 109
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081-3171
Practice Address - Country:US
Practice Address - Phone:972-669-9060
Practice Address - Fax:972-669-4108
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18958122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist