Healthcare Provider Details

I. General information

NPI: 1801993605
Provider Name (Legal Business Name): PAUL EDWARD ANDERSON JR. MD, DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 05/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

262 S PEACHTREE PKWY SUITE 1
PEACHTREE CITY GA
30269-1751
US

IV. Provider business mailing address

262 S PEACHTREE PKWY SUITE 1
PEACHTREE CITY GA
30269-1751
US

V. Phone/Fax

Practice location:
  • Phone: 770-302-0101
  • Fax: 770-302-0105
Mailing address:
  • Phone: 770-302-0101
  • Fax: 770-302-0105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN012577
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: