Provider Demographics
NPI:1770660599
Name:ANDERSON, MARK ALTER (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALTER
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 1:119 BRADFORD LN
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:MO
Mailing Address - Zip Code:64012-2086
Mailing Address - Country:US
Mailing Address - Phone:816-331-9802
Mailing Address - Fax:816-331-9804
Practice Address - Street 1:119 BRADFORD LN
Practice Address - Street 2:
Practice Address - City:BELTON
Practice Address - State:MO
Practice Address - Zip Code:64012-2086
Practice Address - Country:US
Practice Address - Phone:816-331-9802
Practice Address - Fax:816-331-9804
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO139901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO10312018OtherBCBS PROVIDER NUMBER