Provider Demographics
NPI:1407078066
Name:ANDERSON, MARK WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILLIAM
Last Name:ANDERSON
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 1:10744 E PORTOBELLO AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-1845
Mailing Address - Country:US
Mailing Address - Phone:480-633-3447
Mailing Address - Fax:480-633-3449
Practice Address - Street 1:4824 E BASELINE RD
Practice Address - Street 2:BLDG.3 SUITE 122
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206
Practice Address - Country:US
Practice Address - Phone:480-633-3447
Practice Address - Fax:480-633-3449
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ48211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice