Provider Demographics
NPI:1144438946
Name:ANDERSON, DAVID PAUL (DDS)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:PAUL
Last Name:ANDERSON
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 1:555 RIVERGATE
Mailing Address - Street 2:B1-109
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-7470
Mailing Address - Country:US
Mailing Address - Phone:970-422-8498
Mailing Address - Fax:970-422-8498
Practice Address - Street 1:555 RIVERGATE
Practice Address - Street 2:B1-109
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7470
Practice Address - Country:US
Practice Address - Phone:970-422-8498
Practice Address - Fax:970-422-8498
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901015674122300000X
CODEN.002024321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3250025Medicaid
MI15674OtherBLUE CROSS BLUE SHIELD