Healthcare Provider Details

I. General information

NPI: 1437316569
Provider Name (Legal Business Name): BRUCE WILLIAM ANDERSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2008
Last Update Date: 01/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 STEVENS ENTRY
PEACHTREE CITY GA
30269-4050
US

IV. Provider business mailing address

402 STEVENS ENTRY
PEACHTREE CITY GA
30269-4050
US

V. Phone/Fax

Practice location:
  • Phone: 770-487-3807
  • Fax: 770-487-1259
Mailing address:
  • Phone: 770-487-3807
  • Fax: 770-487-1259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN013826
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: