Provider Demographics
NPI:1710243688
Name:ANDERSON, MATTHEW RON (DMD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RON
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 1:90 DOCTORS PARK
Mailing Address - Street 2:SUITE B
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:94505
Mailing Address - Country:US
Mailing Address - Phone:707-526-3303
Mailing Address - Fax:
Practice Address - Street 1:90 DOCTORS PARK
Practice Address - Street 2:SUITE B
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:94505
Practice Address - Country:US
Practice Address - Phone:707-526-3303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-05
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61202122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist