Provider Demographics
NPI:1619192424
Name:ANDERSON, GREGORY EARL (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:EARL
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 1:1395 NO 400 E.
Mailing Address - Street 2:STE B
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341
Mailing Address - Country:US
Mailing Address - Phone:435-755-5000
Mailing Address - Fax:435-755-5099
Practice Address - Street 1:1395 NO. 400 E.
Practice Address - Street 2:STE B
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341
Practice Address - Country:US
Practice Address - Phone:435-755-5000
Practice Address - Fax:435-755-5099
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT145198-9924204E00000X
UT14519899242086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT$$$$$$$$$011Medicaid