=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568792091
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANDERSEN FAMILY DENTISTRY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2010
-----------------------------------------------------
Last Update Date | 01/06/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 186 MAIN ST
-----------------------------------------------------
City | LITTLETON
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03561-4014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-444-6811
-----------------------------------------------------
Fax | 603-444-7052
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 186 MAIN ST
-----------------------------------------------------
City | LITTLETON
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03561-4014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-444-6811
-----------------------------------------------------
Fax | 603-444-7052
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MR. ROBERT JORGEN ANDERSEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 603-444-6811
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | NH03157
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------