Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | 401004978 | VA |
NPI | 1033505193 |
---|---|
Provider Name | Robert Anderson |
First Address | Suffolk, VA 23434-4206 |
Second Address | Suffolk, VA 23434-4206 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/04/2015 |
Last Update Date | 15/04/2015 |