Provider Demographics
NPI:1467793802
Name:ANDERSON, MARCUS WENDELL
Entity Type:Individual
Prefix:MR
First Name:MARCUS
Middle Name:WENDELL
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 1:25360 SHIAWASSEE CIR APT 203
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3861
Mailing Address - Country:US
Mailing Address - Phone:248-910-8480
Mailing Address - Fax:
Practice Address - Street 1:25360 SHIAWASSEE CIR APT 203
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-3861
Practice Address - Country:US
Practice Address - Phone:248-910-8480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist