Provider Demographics
NPI:1942639570
Name:ANDERSON DENTISTRY BEDFORD, PLLC
Entity Type:Organization
Organization Name:ANDERSON DENTISTRY BEDFORD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:DWAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MBS, MBA
Authorized Official - Phone:817-247-4720
Mailing Address - Street 1:5305 COLLEYVILLE BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034
Mailing Address - Country:US
Mailing Address - Phone:817-485-2111
Mailing Address - Fax:817-656-5704
Practice Address - Street 1:2620 HARWOOD RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-3700
Practice Address - Country:US
Practice Address - Phone:817-267-6101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ANDERSON DENTISTRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX291411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty