Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204E00000X | Oral & Maxillofacial Surgeon | 7637 | IA |
NPI | 1588637177 |
---|---|
Provider Name | David Allen Anderson |
First Address | Moline, IL 61265 |
Second Address | Davenport, IA 52807-2762 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/02/2006 |
Last Update Date | 16/07/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0097766 | (05) | IA |
U42048 | (02) |