=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922246537
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANDERSON DENTAL CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2009
-----------------------------------------------------
Last Update Date | 02/04/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22106 HWY 71 W
-----------------------------------------------------
City | SPICEWOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78669-6115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-264-9977
-----------------------------------------------------
Fax | 512-264-9517
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22106 HWY 71 W
-----------------------------------------------------
City | SPICEWOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78669-6115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-264-9977
-----------------------------------------------------
Fax | 512-264-9517
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | CHARLES W ANDERSON
-----------------------------------------------------
Credential | D.D.S
-----------------------------------------------------
Telephone | 512-264-9977
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 9754
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------