Provider Demographics
NPI:1487794806
Name:ANDERSON, MARVIN L
Entity type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 PELHAM RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-2142
Mailing Address - Country:US
Mailing Address - Phone:864-233-3344
Mailing Address - Fax:
Practice Address - Street 1:18 PELHAM RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-2142
Practice Address - Country:US
Practice Address - Phone:864-233-3344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2021-11-08
Deactivation Date:2021-05-11
Deactivation Code:
Reactivation Date:2021-11-08
Provider Licenses
StateLicense IDTaxonomies
SCSC26951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice