Healthcare Provider Details

I. General information

NPI: 1316996010
Provider Name (Legal Business Name): MARK ANDERSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6011 W PIERSON RD
FLUSHING MI
48433-2334
US

IV. Provider business mailing address

6011 W PIERSON RD
FLUSHING MI
48433-2334
US

V. Phone/Fax

Practice location:
  • Phone: 810-733-5566
  • Fax: 810-733-6049
Mailing address:
  • Phone: 810-733-5566
  • Fax: 810-733-6049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901011368
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: