MEDICARE: DR. MARK D. ANDERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	5228	LA

General Provider Information

NPI Number	:	1083843197
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. MARK D. ANDERSON

Provider Business Mailing Address
First Line	:	3625 CANAL ST
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70119-6110
Country	:	US
Telephone Number	:	504-485-6575
Fax Number	:

Provider Business Practice Location Address
First Line	:	3625 CANAL ST
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70119-6110
Country	:	US
Telephone Number	:	504-485-6575
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MARK DAVID ANDERSON
Credential	:	D.D.S.
Telephone Number	:	504-485-6575

Provider Enumeration Date	:	07/09/2009
Last Update Date	:	08/23/2009

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