Provider Demographics
NPI:1407202476
Name:DR. JOHN ANDERSON
Entity Type:Organization
Organization Name:DR. JOHN ANDERSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:256-638-4436
Mailing Address - Street 1:89 CHURCH AVE
Mailing Address - Street 2:PO BOX 646
Mailing Address - City:RAINSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35986-0646
Mailing Address - Country:US
Mailing Address - Phone:256-638-4436
Mailing Address - Fax:256-638-7212
Practice Address - Street 1:89 CHURCH AVE
Practice Address - Street 2:
Practice Address - City:RAINSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35986-0646
Practice Address - Country:US
Practice Address - Phone:256-638-4436
Practice Address - Fax:256-638-7212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD3022122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL90122Medicaid