Provider Demographics
NPI:1043220304
Name:ANDERSON, FARRAH L
Entity Type:Individual
Prefix:
First Name:FARRAH
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:FARRAH
Other - Middle Name:
Other - Last Name:LORZANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1619 W US HIGHWAY 24
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64050-2345
Mailing Address - Country:US
Mailing Address - Phone:816-461-0055
Mailing Address - Fax:
Practice Address - Street 1:1619 W US HIGHWAY 24
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64050-2345
Practice Address - Country:US
Practice Address - Phone:816-461-0055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS604291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200386640AMedicaid