Provider Demographics
NPI:1508912411
Name:ANDERSON, KRESTON (DDS)
Entity Type:Individual
Prefix:
First Name:KRESTON
Middle Name:
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 1:1441 SECRET RAVINE PKWY
Mailing Address - Street 2:#100
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-6044
Mailing Address - Country:US
Mailing Address - Phone:916-782-7783
Mailing Address - Fax:916-782-4699
Practice Address - Street 1:1441 SECRET RAVINE PKWY
Practice Address - Street 2:#100
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-6044
Practice Address - Country:US
Practice Address - Phone:916-782-7783
Practice Address - Fax:916-782-4699
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA367261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice