Provider Demographics
NPI:1174703219
Name:ANDERSON, NATHAN MICHAEL (DMD)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:MICHAEL
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4777 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97478-6069
Mailing Address - Country:US
Mailing Address - Phone:541-357-4888
Mailing Address - Fax:541-357-4846
Practice Address - Street 1:4777 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97478-6069
Practice Address - Country:US
Practice Address - Phone:541-357-4888
Practice Address - Fax:541-357-4846
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-06
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9198122300000X
WY11811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice