Provider Demographics
NPI:1275742488
Name:ANDERSON, JACKSON LAWLER (DDS)
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:LAWLER
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 1:6459 OMAHA BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80915-2618
Mailing Address - Country:US
Mailing Address - Phone:719-597-9057
Mailing Address - Fax:719-597-2189
Practice Address - Street 1:6459 OMAHA BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80915-2618
Practice Address - Country:US
Practice Address - Phone:719-597-9057
Practice Address - Fax:719-597-2189
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1045891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO010274OtherNATIONAL PAYOR ID