Provider Demographics
NPI:1245606060
Name:ANDERSON, MARK STEVEN
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:STEVEN
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68905 VISTA CHINO
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-4866
Mailing Address - Country:US
Mailing Address - Phone:951-444-8805
Mailing Address - Fax:
Practice Address - Street 1:68905 VISTA CHINO
Practice Address - Street 2:
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234-4866
Practice Address - Country:US
Practice Address - Phone:951-444-8805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-16
Last Update Date:2015-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64983122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist