Provider Demographics
NPI:1598790925
Name:ANDERSON, MARY LOU (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:LOU
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LOU
Other - Last Name:ANDERSON-PELLETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2300 LANGLEY AVE
Mailing Address - Street 2:
Mailing Address - City:ST JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085
Mailing Address - Country:US
Mailing Address - Phone:269-983-0159
Mailing Address - Fax:269-983-6444
Practice Address - Street 1:2300 LANGLEY AVE
Practice Address - Street 2:
Practice Address - City:ST JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085
Practice Address - Country:US
Practice Address - Phone:269-983-0159
Practice Address - Fax:269-983-6444
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010131211223G0001X
MI131211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice