Provider Demographics
NPI:1588637177
Name:ANDERSON, DAVID ALLEN (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ALLEN
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 1:3705 39TH ST CT
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265
Mailing Address - Country:US
Mailing Address - Phone:309-736-3130
Mailing Address - Fax:
Practice Address - Street 1:2305 E 52ND ST
Practice Address - Street 2:SUITE 1
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-2762
Practice Address - Country:US
Practice Address - Phone:563-355-9424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA7637204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0097766Medicaid
IA0097766Medicaid
I0172Medicare ID - Type Unspecified