Provider Demographics
NPI:1700999026
Name:ANDERSON, DOUGLAS ROBERT (DDS)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:ROBERT
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 1:141 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-4607
Mailing Address - Country:US
Mailing Address - Phone:614-224-1942
Mailing Address - Fax:614-224-1527
Practice Address - Street 1:141 S 6TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-4607
Practice Address - Country:US
Practice Address - Phone:614-224-1942
Practice Address - Fax:614-224-1527
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-01-46371223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0320325Medicaid
T47246Medicare UPIN
OH0320325Medicaid