Provider Demographics
NPI:1770828246
Name:MILTON, MARK LOUIS (EFDA, RDA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:LOUIS
Last Name:MILTON
Suffix:
Gender:M
Credentials:EFDA, RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 NE 51ST ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-2704
Mailing Address - Country:US
Mailing Address - Phone:360-608-7911
Mailing Address - Fax:
Practice Address - Street 1:14406 NE 20TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-1448
Practice Address - Country:US
Practice Address - Phone:360-571-3139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-10
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR116505126800000X
WAD160053453126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant