Provider Demographics
NPI:1013077650
Name:NORDSTROM, MARC ANDREW (DMD PC)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:ANDREW
Last Name:NORDSTROM
Suffix:
Gender:M
Credentials:DMD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 NW NEWPORT AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-1838
Mailing Address - Country:US
Mailing Address - Phone:541-382-0823
Mailing Address - Fax:541-385-8665
Practice Address - Street 1:108 NW NEWPORT AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-1838
Practice Address - Country:US
Practice Address - Phone:541-382-0823
Practice Address - Fax:541-385-8665
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD73351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice