Provider Demographics
NPI:1932296761
Name:DANIELSON, MARK D (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:DANIELSON
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 1:1550 NW EASTMAN PARKWAY
Mailing Address - Street 2:#265
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030
Mailing Address - Country:US
Mailing Address - Phone:503-665-0495
Mailing Address - Fax:
Practice Address - Street 1:1550 NW EASTMAN PARKWAY
Practice Address - Street 2:#265
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030
Practice Address - Country:US
Practice Address - Phone:503-665-0495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD65481223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics