Provider Demographics
NPI:1467554733
Name:ANDERSON, PAUL CHARLES (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:CHARLES
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:PO BOX 985
Mailing Address - Street 2:
Mailing Address - City:DELTA JUNCTION
Mailing Address - State:AK
Mailing Address - Zip Code:99737-0985
Mailing Address - Country:US
Mailing Address - Phone:907-895-4274
Mailing Address - Fax:
Practice Address - Street 1:2270 NISTLER RD
Practice Address - Street 2:
Practice Address - City:DELTA JUNCTION
Practice Address - State:AK
Practice Address - Zip Code:99737
Practice Address - Country:US
Practice Address - Phone:907-895-4274
Practice Address - Fax:907-895-4276
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK11621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1527523OtherUNITED CONCORDIA
AKDD08701Medicaid