Provider Demographics
NPI:1629262043
Name:ANDERSON, BRIAN G (DDS)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:G
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 1:509 NORTH ACADEMY BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909
Mailing Address - Country:US
Mailing Address - Phone:719-591-7599
Mailing Address - Fax:719-622-9809
Practice Address - Street 1:509 NORTH ACADEMY BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909
Practice Address - Country:US
Practice Address - Phone:719-591-7599
Practice Address - Fax:719-622-9809
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9452122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist