Healthcare Provider Details

I. General information

NPI: 1861029498
Provider Name (Legal Business Name): MARK E VANDUKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5717 E THOMAS RD STE 110
SCOTTSDALE AZ
85251-7620
US

IV. Provider business mailing address

653 S BEEBE ST
GILBERT AZ
85296-0131
US

V. Phone/Fax

Practice location:
  • Phone: 480-207-5070
  • Fax:
Mailing address:
  • Phone: 253-549-8789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD011921
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: