Provider Demographics
NPI:1912050139
Name:ANDERSON, ERIC DAVID (DMD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:DAVID
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 PREMIERE PARKWAY
Mailing Address - Street 2:SUITE 165
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097
Mailing Address - Country:US
Mailing Address - Phone:678-417-9656
Mailing Address - Fax:
Practice Address - Street 1:2925 PREMIERE PARKWAY
Practice Address - Street 2:SUITE 165
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097
Practice Address - Country:US
Practice Address - Phone:678-417-9656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA107551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice