Provider Demographics
NPI:1205842192
Name:ANDERSON, ROBERT LARRY (DDD,PC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LARRY
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DDD,PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 W MULLAN AVE
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50701-1544
Mailing Address - Country:US
Mailing Address - Phone:319-234-2775
Mailing Address - Fax:319-236-1748
Practice Address - Street 1:526 W MULLAN AVE
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-1544
Practice Address - Country:US
Practice Address - Phone:319-234-2775
Practice Address - Fax:319-236-1748
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA5606BJ-00061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0108811Medicaid