Provider Demographics
NPI:1003502477
Name:ANDERSON, ERIC A
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:A
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ERIC
Other - Middle Name:A
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DENTURIST
Mailing Address - Street 1:156 SOUTHPORT DR
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42501-4149
Mailing Address - Country:US
Mailing Address - Phone:606-677-1459
Mailing Address - Fax:
Practice Address - Street 1:156 SOUTHPORT DR
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501-4149
Practice Address - Country:US
Practice Address - Phone:606-677-1459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-17
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDT-DO-10180589122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist