Provider Demographics
NPI:1861578882
Name:ANDERSON, GARY DEAN (DDS)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:DEAN
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 1:3600 E SATE ST.
Mailing Address - Street 2:#306
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108
Mailing Address - Country:US
Mailing Address - Phone:815-399-7799
Mailing Address - Fax:815-877-6895
Practice Address - Street 1:3600 E STATE ST
Practice Address - Street 2:#306
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-1978
Practice Address - Country:US
Practice Address - Phone:815-399-7799
Practice Address - Fax:815-877-6895
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice