Provider Demographics
NPI:1922329713
Name:ANDERSON, ALAN ARTHUR (DPD,CDT)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:ARTHUR
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DPD,CDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1622 S MILDRED ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98465-1610
Mailing Address - Country:US
Mailing Address - Phone:253-588-2721
Mailing Address - Fax:253-984-9366
Practice Address - Street 1:1622 S MILDRED ST
Practice Address - Street 2:SUITE A
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98465-1610
Practice Address - Country:US
Practice Address - Phone:253-588-2721
Practice Address - Fax:253-984-9366
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-16
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN00000119122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1922329713Medicaid