Provider Demographics
NPI:1568514354
Name:ANDERSON, REBECCA JO (DMD)
Entity Type:Individual
Prefix:MISS
First Name:REBECCA
Middle Name:JO
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1156
Mailing Address - Street 2:170 WEST FIFTH STREET
Mailing Address - City:ELKHORN CITY
Mailing Address - State:KY
Mailing Address - Zip Code:41522
Mailing Address - Country:US
Mailing Address - Phone:606-754-7198
Mailing Address - Fax:606-754-7199
Practice Address - Street 1:170 WEST FIFTH STREET
Practice Address - Street 2:
Practice Address - City:ELKHORN CITY
Practice Address - State:KY
Practice Address - Zip Code:41522
Practice Address - Country:US
Practice Address - Phone:606-754-7198
Practice Address - Fax:606-754-7198
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY77681223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60000932Medicare ID - Type Unspecified