Healthcare Provider Details

I. General information

NPI: 1962487926
Provider Name (Legal Business Name): MARVIN PAUL ANDERSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US ARMY DENTAL ACTIVITY 10205 N RIVA RIDGE LOOP
FORT DRUM NY
13602-5005
US

IV. Provider business mailing address

US ARMY DENTAL ACTIVITY 10205 N RIVA RIDGE LOOP
FORT DRUM NY
13602-5005
US

V. Phone/Fax

Practice location:
  • Phone: 315-772-4342
  • Fax: 315-772-9692
Mailing address:
  • Phone: 315-772-4342
  • Fax: 315-772-9692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN 13813
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: