Basic Information
| Provider Information | |||||||||
| NPI: | 1639204860 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4635 SOUTHWEST FWY | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770277169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7138770697 | ||||||||
| FaxNumber: | 7136238380 | ||||||||
| Practice Location | |||||||||
| Address1: | 6911 HIGHWAY 6 S | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770836751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2814380106 | ||||||||
| FaxNumber: | 2815619657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 12927 | TX | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 0092751-03 | 05 | TX | MEDICAID | 0092751-05 | 05 | TX | MEDICAID |