Provider Demographics
NPI:1144330143
Name:ANDERSON, DAMON ASHLEY (DDS)
Entity type:Individual
Prefix:DR
First Name:DAMON
Middle Name:ASHLEY
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 1:25500 RANCHO NIGUEL RD STE 260
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-7306
Mailing Address - Country:US
Mailing Address - Phone:949-643-3129
Mailing Address - Fax:949-643-5259
Practice Address - Street 1:25500 RANCHO NIGUEL RD STE 260
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-7306
Practice Address - Country:US
Practice Address - Phone:949-643-3129
Practice Address - Fax:949-643-5259
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104929122300000X
WADE009260122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03397748Medicaid