Provider Demographics
NPI:1528270634
Name:BOTTORFF, MARK WILLIAM (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILLIAM
Last Name:BOTTORFF
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 1:1324 N. LIBERTY LAKE RD
Mailing Address - Street 2:STE 345
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019
Mailing Address - Country:US
Mailing Address - Phone:509-808-9766
Mailing Address - Fax:509-891-8999
Practice Address - Street 1:323 S. GREENRIDGE DR.
Practice Address - Street 2:
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019
Practice Address - Country:US
Practice Address - Phone:509-808-9766
Practice Address - Fax:509-891-8999
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2025-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAGA100003661223D0004X
WADE000097931223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0004XDental ProvidersDentistDental Anesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA20069362Medicaid