Provider Demographics
NPI:1033254859
Name:ANDERSON, RICHARD P (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:P
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 1:1804 BUENA VISTA ST
Mailing Address - Street 2:COR. BUENA VISTA AND TRINITY
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-3805
Mailing Address - Country:US
Mailing Address - Phone:210-227-9921
Mailing Address - Fax:210-223-4081
Practice Address - Street 1:1804 BUENA VISTA ST
Practice Address - Street 2:COR. BUENA VISTA AND TRINITY
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-3805
Practice Address - Country:US
Practice Address - Phone:210-227-9921
Practice Address - Fax:210-223-4081
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9649122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00790701Medicaid