Provider Demographics
NPI:1598214439
Name:ERIC ANDERSEN PA
Entity Type:Organization
Organization Name:ERIC ANDERSEN PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:ANDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-340-5565
Mailing Address - Street 1:400 N ALLEN DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-2555
Mailing Address - Country:US
Mailing Address - Phone:972-727-4415
Mailing Address - Fax:
Practice Address - Street 1:400 N ALLEN DR
Practice Address - Street 2:SUITE 101
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-2555
Practice Address - Country:US
Practice Address - Phone:972-727-4415
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30758122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty