Healthcare Provider Details

I. General information

NPI: 1629484522
Provider Name (Legal Business Name): DEVIN ANDERSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2014
Last Update Date: 07/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11261 WAREHAM CT
LOMA LINDA CA
92354-4875
US

IV. Provider business mailing address

11261 WAREHAM CT
LOMA LINDA CA
92354-4875
US

V. Phone/Fax

Practice location:
  • Phone: 909-496-1718
  • Fax: 909-478-0778
Mailing address:
  • Phone: 909-496-1718
  • Fax: 909-478-0778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number46353
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: