MEDICARE: DR. PAUL & DR. ANDERSON, DENTAL PC

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	1223G0001X	General Practice Dentistry	1916423	IL

General Provider Information

NPI Number	:	1154728228
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. PAUL & DR. ANDERSON, DENTAL PC

Provider Business Mailing Address
First Line	:	521 W. LAKE AVE
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61614
Country	:	US
Telephone Number	:	309-682-0770
Fax Number	:

Provider Business Practice Location Address
First Line	:	521 W LAKE AVE
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61614-6020
Country	:	US
Telephone Number	:	309-682-0770
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	ROGER PAUL
Credential	:	DMD
Telephone Number	:	309-682-0770

Provider Enumeration Date	:	12/04/2014
Last Update Date	:	12/04/2014

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