Provider Demographics
NPI:1588728885
Name:ANDERSON, JOHN MARK (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MARK
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 1:4206 FAIRVIEW LN
Mailing Address - Street 2:
Mailing Address - City:MADISON LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56063-9515
Mailing Address - Country:US
Mailing Address - Phone:507-243-3888
Mailing Address - Fax:
Practice Address - Street 1:530 W PLEASANT ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-0438
Practice Address - Country:US
Practice Address - Phone:507-345-6478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND102591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice