Provider Demographics
NPI:1992836449
Name:ANDERSON, ABRAM S (DDS)
Entity Type:Individual
Prefix:DR
First Name:ABRAM
Middle Name:S
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 1:702 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANAMOSA
Mailing Address - State:IA
Mailing Address - Zip Code:52205-1636
Mailing Address - Country:US
Mailing Address - Phone:319-462-2531
Mailing Address - Fax:319-462-2914
Practice Address - Street 1:702 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ANAMOSA
Practice Address - State:IA
Practice Address - Zip Code:52205-1636
Practice Address - Country:US
Practice Address - Phone:319-462-2531
Practice Address - Fax:319-462-2914
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA083711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0470393Medicaid
IA42053OtherDELTA DENTAL
IA0470393Medicaid