Provider Demographics
NPI:1043610165
Name:WILLOW DENTAL GROUP
Entity Type:Organization
Organization Name:WILLOW DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:E
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:559-434-1088
Mailing Address - Street 1:6753 N WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-5900
Mailing Address - Country:US
Mailing Address - Phone:559-434-1088
Mailing Address - Fax:
Practice Address - Street 1:6753 N WILLOW AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5900
Practice Address - Country:US
Practice Address - Phone:559-434-1088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-26
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty