Provider Demographics
NPI:1275551319
Name:ANDERSON, MICHAEL EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EDWARD
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 1:18709 CRESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-2705
Mailing Address - Country:US
Mailing Address - Phone:301-797-6841
Mailing Address - Fax:301-739-7965
Practice Address - Street 1:18709 CRESTWOOD DR
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-2705
Practice Address - Country:US
Practice Address - Phone:301-797-6841
Practice Address - Fax:301-739-7965
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD54131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAZBE686OtherBC/BS OF MA
1637929OtherUNITED CONCORDIA
5926263OtherAETNA
MD1102OtherBC/BS OF MD