Provider Demographics
NPI:1043320997
Name:ANDERBERG, GARY NELSON (DMD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:NELSON
Last Name:ANDERBERG
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 1:26140 VIEWLAND DR
Mailing Address - Street 2:
Mailing Address - City:DAMASCUS
Mailing Address - State:MD
Mailing Address - Zip Code:20872-1231
Mailing Address - Country:US
Mailing Address - Phone:301-253-4606
Mailing Address - Fax:
Practice Address - Street 1:16105 FREDERICK RD
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:MD
Practice Address - Zip Code:21765
Practice Address - Country:US
Practice Address - Phone:410-489-4900
Practice Address - Fax:410-489-4900
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD62471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice