Provider Demographics
NPI:1245363308
Name:RITTENHOUSE, ALFORD MARK (LD)
Entity type:Individual
Prefix:
First Name:ALFORD
Middle Name:MARK
Last Name:RITTENHOUSE
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 FOX CT
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59404-3874
Mailing Address - Country:US
Mailing Address - Phone:406-761-4722
Mailing Address - Fax:
Practice Address - Street 1:2509 7TH AVE S STE D1
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-3031
Practice Address - Country:US
Practice Address - Phone:406-453-5808
Practice Address - Fax:406-453-5899
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT16122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0150176Medicaid