Provider Demographics
NPI:1265012785
Name:ANDERSON, JEFFREY THOMAS
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:THOMAS
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3120 RIDGES BND APT 203
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-5437
Mailing Address - Country:US
Mailing Address - Phone:419-304-6814
Mailing Address - Fax:
Practice Address - Street 1:12723 N BELLWOOD DR STE 20
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-7275
Practice Address - Country:US
Practice Address - Phone:616-377-7333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-09
Last Update Date:2024-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29036037631223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry