Provider Demographics
NPI:1063683233
Name:ANDERSON, KENNETH LEE (RDH)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:LEE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 MULDOON RD APT 5
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-1435
Mailing Address - Country:US
Mailing Address - Phone:402-740-8740
Mailing Address - Fax:641-795-2883
Practice Address - Street 1:111 MULDOON RD APT 5
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-1435
Practice Address - Country:US
Practice Address - Phone:402-740-8740
Practice Address - Fax:641-795-2883
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH-905320124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist