Basic Information
| Provider Information | |||||||||
| NPI: | 1962487926 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | MARVIN | ||||||||
| MiddleName: | PAUL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | US ARMY DENTAL ACTIVITY | ||||||||
| Address2: | 10205 N RIVA RIDGE LOOP | ||||||||
| City: | FORT DRUM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136025005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157724342 | ||||||||
| FaxNumber: | 3157729692 | ||||||||
| Practice Location | |||||||||
| Address1: | US ARMY DENTAL ACTIVITY | ||||||||
| Address2: | 10205 N RIVA RIDGE LOOP | ||||||||
| City: | FORT DRUM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136025005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157724342 | ||||||||
| FaxNumber: | 3157729692 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2005 | ||||||||
| 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 | 1223S0112X | DN 13813 | FL | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
No ID Information.