Provider Demographics
NPI:1326231267
Name:ANDERSON, JOHN ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ALAN
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 1:4122 SHELBYVILLE ROAD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207
Mailing Address - Country:US
Mailing Address - Phone:502-895-6930
Mailing Address - Fax:502-894-9044
Practice Address - Street 1:4122 SHELBYVILLE ROAD
Practice Address - Street 2:SUITE 103
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207
Practice Address - Country:US
Practice Address - Phone:502-895-6930
Practice Address - Fax:502-894-9044
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-23
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7547122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60001757Medicaid
IN201369460Medicaid