Provider Demographics
NPI:1760608913
Name:ANDERSON, MICHAEL C (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
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 1:2025 W GRANT RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-1101
Mailing Address - Country:US
Mailing Address - Phone:520-294-4444
Mailing Address - Fax:520-294-8600
Practice Address - Street 1:2025 W GRANT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-1101
Practice Address - Country:US
Practice Address - Phone:520-294-4444
Practice Address - Fax:520-294-8600
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice