Provider Demographics
NPI:1477558369
Name:ANDERSON, MICHAEL JOSEPH (DDS)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOSEPH
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 1:610 NORTH RANGE AVENUE
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-2900
Mailing Address - Country:US
Mailing Address - Phone:225-665-1212
Mailing Address - Fax:225-664-7404
Practice Address - Street 1:610 NORTH RANGE AVENUE
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726-2900
Practice Address - Country:US
Practice Address - Phone:225-665-1212
Practice Address - Fax:225-664-7404
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA52601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice