MEDICARE: SEAN ANDERSON, D.D.S., INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	42519	CA

General Provider Information

NPI Number	:	1023224227
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEAN ANDERSON, D.D.S., INC.

Provider Business Mailing Address
First Line	:	1501 BOLLINGER CANYON RD
Second Line	:	STE. G
City	:	SAN RAMON
State	:	CA
Zip	:	94583-1758
Country	:	US
Telephone Number	:	925-837-4486
Fax Number	:	925-837-8164

Provider Business Practice Location Address
First Line	:	1501 BOLLINGER CANYON RD
Second Line	:	STE. G
City	:	SAN RAMON
State	:	CA
Zip	:	94583-1758
Country	:	US
Telephone Number	:	925-837-4486
Fax Number	:	925-837-8164

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SEAN MICHAEL ANDERSON
Credential	:	D.D.S.
Telephone Number	:	925-837-4486

Provider Enumeration Date	:	05/15/2007
Last Update Date	:	08/22/2020

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