Provider Demographics
NPI:1154447340
Name:ANDERSON, JIMMIE SCOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:JIMMIE
Middle Name:SCOTT
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1819 E INNES ST STE 2
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28146-6030
Mailing Address - Country:US
Mailing Address - Phone:704-636-3611
Mailing Address - Fax:704-636-3694
Practice Address - Street 1:1819 E INNES ST STE 2
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28146-6030
Practice Address - Country:US
Practice Address - Phone:704-636-3611
Practice Address - Fax:704-636-3694
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC67931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1895938OtherUNITED CONCORDIA
NC81058849OtherBCBS OF ALABAMA
NC4074378OtherBCBS OF TENNESSEE
NC899011EMedicaid