Healthcare Provider Details

I. General information

NPI: 1528270634
Provider Name (Legal Business Name): MARK WILLIAM BOTTORFF DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 08/04/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 S. GREENRIDGE DR.
LIBERTY LAKE WA
99019
US

IV. Provider business mailing address

1324 N. LIBERTY LAKE RD STE 345
LIBERTY LAKE WA
99019
US

V. Phone/Fax

Practice location:
  • Phone: 509-808-9766
  • Fax: 509-891-8999
Mailing address:
  • Phone: 509-808-9766
  • Fax: 509-891-8999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License NumberGA10000366
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License NumberDE00009793
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: