Provider Demographics
NPI:1386634392
Name:ANDERSON, BRYAN D (DD S)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:D
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DD S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2807 S STONE ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223-4904
Mailing Address - Country:US
Mailing Address - Phone:509-624-7151
Mailing Address - Fax:509-624-2145
Practice Address - Street 1:2807 S STONE ST
Practice Address - Street 2:SUITE 102
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-4904
Practice Address - Country:US
Practice Address - Phone:509-624-7151
Practice Address - Fax:509-624-2145
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5005772Medicaid