Healthcare Provider Details

I. General information

NPI: 1861067464
Provider Name (Legal Business Name): NATHAN ANDERSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2021
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1395 N 400 E
LOGAN UT
84341-7530
US

IV. Provider business mailing address

1395 N 400 E STE B
LOGAN UT
84341-7531
US

V. Phone/Fax

Practice location:
  • Phone: 435-755-5000
  • Fax:
Mailing address:
  • Phone: 435-755-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number14206222-9926
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: