Provider Demographics
NPI:1619952314
Name:ANDERSON, JAMES GREGORY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:GREGORY
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 1:2130 N CHARLES G SEIVERS BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:TN
Mailing Address - Zip Code:37716-6705
Mailing Address - Country:US
Mailing Address - Phone:865-622-4959
Mailing Address - Fax:865-269-4336
Practice Address - Street 1:2130 N CHARLES G SEIVERS BLVD STE 1
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:TN
Practice Address - Zip Code:37716-6705
Practice Address - Country:US
Practice Address - Phone:865-622-4959
Practice Address - Fax:865-269-4336
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000053901223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1511863Medicaid
TN1511863Medicaid