=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679789200
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANDERSON AND ANDERSON DMD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2925 PREMIERE PARKWAY SUITE 165
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30097
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-417-9656
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2925 PREMIERE PARKWAY SUITE 165
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30097
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-417-9656
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ERIC DAVID ANDERSON
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 678-417-9656
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 10755
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------