Provider Demographics
NPI:1710152517
Name:ANDERSON, THOMAS NEAL (DDS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:NEAL
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 1:25432 TRABUCO RD
Mailing Address - Street 2:#206
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-2758
Mailing Address - Country:US
Mailing Address - Phone:949-380-7803
Mailing Address - Fax:949-380-7823
Practice Address - Street 1:25432 TRABUCO RD
Practice Address - Street 2:#206
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-2758
Practice Address - Country:US
Practice Address - Phone:949-380-7803
Practice Address - Fax:949-380-7823
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31557122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist