Provider Demographics
NPI:1346319183
Name:ANDERSON, THOMAS A (DDS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
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 1:1935 1ST AVE SE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-5332
Mailing Address - Country:US
Mailing Address - Phone:319-364-7108
Mailing Address - Fax:319-364-6529
Practice Address - Street 1:1935 1ST AVE SE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-5332
Practice Address - Country:US
Practice Address - Phone:319-364-7108
Practice Address - Fax:319-364-6529
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA065501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0170597Medicaid