Provider Demographics
NPI:1619250792
Name:PAUL V ANDERSON DDS LLC
Entity type:Organization
Organization Name:PAUL V ANDERSON DDS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:VERNON
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:541-471-1990
Mailing Address - Street 1:2900 NW VINE ST
Mailing Address - Street 2:SUITE L
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-8411
Mailing Address - Country:US
Mailing Address - Phone:541-471-1990
Mailing Address - Fax:541-471-0325
Practice Address - Street 1:2900 NW VINE ST
Practice Address - Street 2:SUITE L
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-8411
Practice Address - Country:US
Practice Address - Phone:541-471-1990
Practice Address - Fax:541-471-0325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-24
Last Update Date:2011-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD95791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty