Healthcare Provider Details

I. General information

NPI: 1083624621
Provider Name (Legal Business Name): DAVID CHARLES ANDERSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 MAIN ST
GREEN BAY WI
54301-5115
US

IV. Provider business mailing address

5318 NORTH ROSEMARY LANE
APPLETON WI
54913
US

V. Phone/Fax

Practice location:
  • Phone: 920-431-0345
  • Fax:
Mailing address:
  • Phone: 920-730-9027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number5956
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: