Healthcare Provider Details

I. General information

NPI: 1144490707
Provider Name (Legal Business Name): MISSISSIPPI VALLEY ORAL & MAXILLOFACIAL SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2008
Last Update Date: 03/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2305 E 52ND ST SUITE 1
DAVENPORT IA
52807-2762
US

IV. Provider business mailing address

2305 E 52ND ST SUITE 1
DAVENPORT IA
52807-2762
US

V. Phone/Fax

Practice location:
  • Phone: 563-355-9424
  • Fax: 563-355-0180
Mailing address:
  • Phone: 563-355-9424
  • Fax: 563-355-0180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number7637
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number7766
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number7839
License Number StateIA

VIII. Authorized Official

Name: DR. DAVID A ANDERSON
Title or Position: OWNER/DOCTOR
Credential: DDS
Phone: 563-355-9424