Healthcare Provider Details

I. General information

NPI: 1073864963
Provider Name (Legal Business Name): MATTHEW ROSS ANDERSON D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2012
Last Update Date: 05/10/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14400 NE 20TH AVE STE 100
VANCOUVER WA
98686-1412
US

IV. Provider business mailing address

14400 NE 20TH AVE STE 100
VANCOUVER WA
98686-1412
US

V. Phone/Fax

Practice location:
  • Phone: 360-576-5066
  • Fax:
Mailing address:
  • Phone: 360-576-5066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number8418211-9921
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD11375
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number8418211-9921
License Number StateUT
# 4
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDE60944562
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: