Provider Demographics
NPI:1962793968
Name:ROBERT E ANDERSON DDS A PROFESSIONAL DENTAL CORP
Entity type:Organization
Organization Name:ROBERT E ANDERSON DDS A PROFESSIONAL DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:530-622-9068
Mailing Address - Street 1:4300 GOLDEN CENTER DR
Mailing Address - Street 2:SUITE G
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-6278
Mailing Address - Country:US
Mailing Address - Phone:530-622-9068
Mailing Address - Fax:530-622-9055
Practice Address - Street 1:4300 GOLDEN CENTER DR
Practice Address - Street 2:SUITE G
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-6278
Practice Address - Country:US
Practice Address - Phone:530-622-9068
Practice Address - Fax:530-622-9055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-25
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA971931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty