Provider Demographics
NPI:1790837391
Name:ANDERSON, ROBERT LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LEE
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 1:7654 HICKMAN RD
Mailing Address - Street 2:
Mailing Address - City:WINDSOR HEIGHTS
Mailing Address - State:IA
Mailing Address - Zip Code:50322-4510
Mailing Address - Country:US
Mailing Address - Phone:515-276-9330
Mailing Address - Fax:515-276-0396
Practice Address - Street 1:7654 HICKMAN RD
Practice Address - Street 2:
Practice Address - City:WINDSOR HEIGHTS
Practice Address - State:IA
Practice Address - Zip Code:50322-4510
Practice Address - Country:US
Practice Address - Phone:515-276-9330
Practice Address - Fax:515-276-0396
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA073691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA03761OtherPROVIDER NUMBER
IA0102392Medicaid