Provider Demographics
NPI:1659467827
Name:ANDERSON, KITRIDGE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KITRIDGE
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 1:4080 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:ONAWAY
Mailing Address - State:MI
Mailing Address - Zip Code:49765-8852
Mailing Address - Country:US
Mailing Address - Phone:989-733-8533
Mailing Address - Fax:989-733-9915
Practice Address - Street 1:4080 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:ONAWAY
Practice Address - State:MI
Practice Address - Zip Code:49765-8852
Practice Address - Country:US
Practice Address - Phone:989-733-8533
Practice Address - Fax:989-733-9915
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI173751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6394950001Medicare NSC