Provider Demographics
NPI:1851302228
Name:ANDERSON, MATTHEW BOYD (DDS)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:BOYD
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 1:5189 UTICA RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3863
Mailing Address - Country:US
Mailing Address - Phone:563-355-2010
Mailing Address - Fax:563-355-3191
Practice Address - Street 1:5189 UTICA RIDGE RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3863
Practice Address - Country:US
Practice Address - Phone:563-355-2010
Practice Address - Fax:563-355-3191
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA078921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA12002OtherBC/BS PROVIDER
IA973821OtherUNITED CONCORDIA PROVIDER