Provider Demographics
NPI:1003052234
Name:ROBERT E. ANDERSON, DDS, PA
Entity Type:Organization
Organization Name:ROBERT E. ANDERSON, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL & MAXILLOFACIAL SURGEON
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:501-664-3900
Mailing Address - Street 1:1 SAINT VINCENT CIR STE 240
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5407
Mailing Address - Country:US
Mailing Address - Phone:501-664-3900
Mailing Address - Fax:501-663-6076
Practice Address - Street 1:1 SAINT VINCENT CIR STE 240
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5407
Practice Address - Country:US
Practice Address - Phone:501-664-3900
Practice Address - Fax:501-663-6076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-17
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR17291223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR127328679Medicaid