Healthcare Provider Details

I. General information

NPI: 1770628976
Provider Name (Legal Business Name): JAMES R. ANDERSON DMD, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19059 SE DIVISION ST
GRESHAM OR
97030-5165
US

IV. Provider business mailing address

19059 SE DIVISION ST
GRESHAM OR
97030-5165
US

V. Phone/Fax

Practice location:
  • Phone: 503-761-4711
  • Fax: 503-761-4976
Mailing address:
  • Phone: 503-761-4711
  • Fax: 503-761-4976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberD7285
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. JAMES R. ANDERSON
Title or Position: PRESIDENT
Credential: DMD
Phone: 503-761-4711