Healthcare Provider Details

I. General information

NPI: 1598967101
Provider Name (Legal Business Name): CLINTON DALE ANDERSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 05/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 JACKSON RIVER RD
MONTEREY VA
24465
US

IV. Provider business mailing address

164 JACKSON RIVER RD
MONTEREY VA
24465
US

V. Phone/Fax

Practice location:
  • Phone: 540-468-3500
  • Fax:
Mailing address:
  • Phone: 540-468-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401411783
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: