Provider Demographics
NPI:1700015435
Name:ANDERSON, CLAY WESLEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:CLAY
Middle Name:WESLEY
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 1:1409 N. 12TH STREET
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:OK
Mailing Address - Zip Code:73542
Mailing Address - Country:US
Mailing Address - Phone:580-335-2263
Mailing Address - Fax:580-335-2283
Practice Address - Street 1:1409 N 12TH ST
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:OK
Practice Address - Zip Code:73542-2020
Practice Address - Country:US
Practice Address - Phone:580-335-2263
Practice Address - Fax:580-335-2283
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-02
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK60951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice