Healthcare Provider Details

I. General information

NPI: 1437200854
Provider Name (Legal Business Name): MARK W AN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11811 MUKILTEO SPEEDWAY SUITE 102
MUKILTEO WA
98275-5442
US

IV. Provider business mailing address

11811 MUKILTEO SPEEDWAY SUITE 102
MUKILTEO WA
98275-5442
US

V. Phone/Fax

Practice location:
  • Phone: 425-267-9900
  • Fax: 425-267-9901
Mailing address:
  • Phone: 425-267-9900
  • Fax: 425-267-9901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE00010456
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier5050968
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: