Provider Demographics
NPI:1568699817
Name:ANDERSON, JANTZEN LYNN (DDS)
Entity Type:Individual
Prefix:
First Name:JANTZEN
Middle Name:LYNN
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 1:5430 TUTT BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80922-2515
Mailing Address - Country:US
Mailing Address - Phone:719-591-5437
Mailing Address - Fax:
Practice Address - Street 1:5430 TUTT BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80922-2515
Practice Address - Country:US
Practice Address - Phone:719-591-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-14
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0024713122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0024713OtherTEXAS DENTAL LICENSE
CO10747OtherCOLORADO DENTAL LICENSE