Provider Demographics
NPI: | 1013033851 |
---|---|
Name: | ANDERSON DENTAL, LLC |
Entity Type: | Organization |
Organization Name: | ANDERSON DENTAL, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | LEON |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | ANDERSON |
Authorized Official - Suffix: | JR |
Authorized Official - Credentials: | DMD |
Authorized Official - Phone: | 601-366-1112 |
Mailing Address - Street 1: | P.O. BOX 11277 |
Mailing Address - Street 2: | |
Mailing Address - City: | JACKSON |
Mailing Address - State: | MS |
Mailing Address - Zip Code: | 39283-1277 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 601-366-1112 |
Mailing Address - Fax: | 601-366-6092 |
Practice Address - Street 1: | 514-D EAST WOODROW WILSON DR. |
Practice Address - Street 2: | |
Practice Address - City: | JACKSON |
Practice Address - State: | MS |
Practice Address - Zip Code: | 39216-4538 |
Practice Address - Country: | US |
Practice Address - Phone: | 601-366-1112 |
Practice Address - Fax: | 601-366-6092 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-03-22 |
Last Update Date: | 2020-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MS | MS2164-85 | 1223G0001X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Single Specialty |