Provider Demographics
NPI:1184787657
Name:ANDERSON, ROGER WYNN (DDS)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:WYNN
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 1:1477 SAN MARINO AVENUE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91108-2053
Mailing Address - Country:US
Mailing Address - Phone:625-796-6371
Mailing Address - Fax:626-449-6947
Practice Address - Street 1:1477 SAN MARINO AVENUE
Practice Address - Street 2:SUITE 1
Practice Address - City:SAN MARINO
Practice Address - State:CA
Practice Address - Zip Code:91108-2053
Practice Address - Country:US
Practice Address - Phone:625-796-6371
Practice Address - Fax:626-449-6947
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA337201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice