Mark Lance Ethridge, D.D.S.

Primary specialty

DentistTaxonomy code 122300000X

License

18958 Issued in TX

Practice address

1101 N Jupiter Rd
Suite 109
Richardson, TX 75081-3171

Phone

(972) 669-9060

Fax

(972) 669-4108

NPI assigned

Sep 28, 2006

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in TX

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1159401600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1164513685",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1101 N JUPITER RD",
            "address_2": "SUITE 109",
            "city": "RICHARDSON",
            "state": "TX",
            "postal_code": "750813171",
            "telephone_number": "972-669-9060",
            "fax_number": "972-669-4108"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1101 N JUPITER RD",
            "address_2": "SUITE 109",
            "city": "RICHARDSON",
            "state": "TX",
            "postal_code": "750813171",
            "telephone_number": "972-669-9060",
            "fax_number": "972-669-4108"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ETHRIDGE",
        "first_name": "MARK",
        "middle_name": "LANCE",
        "name_prefix": "Dr.",
        "credential": "D.D.S.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-09-28",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "TX",
            "license": "18958",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Dentist in Richardson, TX
• Providers in Richardson, TX by specialty
• Dentist in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.