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
StateLicense IDTaxonomies
MSMS2164-851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty