Provider Demographics
NPI:1780716969
Name:ANDERSON, MARK WAYNE (DDS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WAYNE
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 1:995 OLIVER ROAD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-4349
Mailing Address - Country:US
Mailing Address - Phone:707-425-0646
Mailing Address - Fax:707-425-0777
Practice Address - Street 1:995 OLIVER ROAD
Practice Address - Street 2:SUITE 10
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-4349
Practice Address - Country:US
Practice Address - Phone:707-425-0646
Practice Address - Fax:707-425-0777
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD33437122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10198992OtherEMPLOYER ACCT NUMBER