Provider Demographics
NPI:1780061879
Name:CHAD J. ANDERSON DENTAL CORPORATION
Entity type:Organization
Organization Name:CHAD J. ANDERSON DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:559-434-1096
Mailing Address - Street 1:9497 N FORT WASHINGTON RD STE 106
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93730-0606
Mailing Address - Country:US
Mailing Address - Phone:559-434-1096
Mailing Address - Fax:559-434-1799
Practice Address - Street 1:5084 N FRUIT AVE STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3000
Practice Address - Country:US
Practice Address - Phone:559-226-3686
Practice Address - Fax:559-226-0947
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHAD J. ANDERSON DENTAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-28
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52822122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty