Provider Demographics
NPI:1952735524
Name:ANDERSON, ROBERT E (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:E
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 1:14060 MARQUESAS WAY APT 2301
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-7499
Mailing Address - Country:US
Mailing Address - Phone:503-704-3957
Mailing Address - Fax:
Practice Address - Street 1:4940 VAN NUYS BLVD STE 101
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1773
Practice Address - Country:US
Practice Address - Phone:818-789-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-30
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA624031223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics