Provider Demographics
NPI:1245751114
Name:ANDERSON, PAYDEN BLAKE (DMD)
Entity Type:Individual
Prefix:DR
First Name:PAYDEN
Middle Name:BLAKE
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:PO BOX 222
Mailing Address - Street 2:
Mailing Address - City:LOGANDALE
Mailing Address - State:NV
Mailing Address - Zip Code:89021-0222
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1170 N MOAPA VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:OVERTON
Practice Address - State:NV
Practice Address - Zip Code:89040-9098
Practice Address - Country:US
Practice Address - Phone:702-398-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-30
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6952122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist