Healthcare Provider Details

I. General information

NPI: 1770828246
Provider Name (Legal Business Name): MARK LOUIS MILTON EFDA, RDA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2012
Last Update Date: 12/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14406 NE 20TH AVE
VANCOUVER WA
98686-1448
US

IV. Provider business mailing address

4100 NE 51ST ST
VANCOUVER WA
98661-2704
US

V. Phone/Fax

Practice location:
  • Phone: 360-571-3139
  • Fax:
Mailing address:
  • Phone: 360-608-7911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number116505
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberD160053453
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: