Provider Demographics
NPI:1619975281
Name:ANDERSON, GERALD ELLIS (DMD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:ELLIS
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3975 RIVER RD N
Mailing Address - Street 2:SUITE #5
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-4811
Mailing Address - Country:US
Mailing Address - Phone:503-393-9106
Mailing Address - Fax:503-393-3053
Practice Address - Street 1:3975 RIVER RD N
Practice Address - Street 2:SUITE #5
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-4811
Practice Address - Country:US
Practice Address - Phone:503-393-9106
Practice Address - Fax:503-393-3053
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD4704122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORD4704OtherOREGON DENTAL LICENSE #
OR0250011-8OtherOREGON BUSINESS ID #
OR00454-9Medicaid