Provider Demographics
NPI:1316996010
Name:ANDERSON, MARK (DDS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
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 1:6011 W PIERSON RD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:MI
Mailing Address - Zip Code:48433-2334
Mailing Address - Country:US
Mailing Address - Phone:810-733-5566
Mailing Address - Fax:810-733-6049
Practice Address - Street 1:6011 W PIERSON RD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:MI
Practice Address - Zip Code:48433-2334
Practice Address - Country:US
Practice Address - Phone:810-733-5566
Practice Address - Fax:810-733-6049
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010113681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice