Provider Demographics
NPI:1265558605
Name:ANDERSON, RICHARD P (DDS)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:P
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1252 AIRPORT PARK BLVD STE D1
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-5979
Mailing Address - Country:US
Mailing Address - Phone:707-462-8719
Mailing Address - Fax:707-472-0921
Practice Address - Street 1:1252 AIRPORT PARK BLVD STE D1
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-5979
Practice Address - Country:US
Practice Address - Phone:707-462-8719
Practice Address - Fax:707-472-0921
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA580081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice