Provider Demographics
NPI:1518177815
Name:HIGGINBOTTOM, MARK ALLAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLAN
Last Name:HIGGINBOTTOM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:556A CYNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-3805
Mailing Address - Country:US
Mailing Address - Phone:410-822-3626
Mailing Address - Fax:410-822-9520
Practice Address - Street 1:556A CYNWOOD DR
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-3805
Practice Address - Country:US
Practice Address - Phone:410-822-3626
Practice Address - Fax:410-822-9520
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD57891223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics