Healthcare Provider Details

I. General information

NPI: 1124034251
Provider Name (Legal Business Name): ROBERT ANDERSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 06/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3775 STOCKTON HILL RD STE C
KINGMAN AZ
86409
US

IV. Provider business mailing address

3775 STOCKTON HILL RD STE C
KINGMAN AZ
86409
US

V. Phone/Fax

Practice location:
  • Phone: 928-692-9135
  • Fax: 928-692-9408
Mailing address:
  • Phone: 928-692-9135
  • Fax: 928-692-9408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD-3383
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD008607
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: