Provider Demographics
NPI:1730222357
Name:NORDLIE, MARK D (DDS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:NORDLIE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32020 1ST AVE S
Mailing Address - Street 2:#117
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-5717
Mailing Address - Country:US
Mailing Address - Phone:253-838-6314
Mailing Address - Fax:
Practice Address - Street 1:32020 1ST AVE S
Practice Address - Street 2:#117
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5717
Practice Address - Country:US
Practice Address - Phone:253-838-6314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA64901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice