Provider Demographics
NPI:1659668762
Name:ANDERSON, KATHLEEN E (DMD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:E
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 1:1206 BURNING TREE LN
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-5123
Mailing Address - Country:US
Mailing Address - Phone:352-339-0959
Mailing Address - Fax:
Practice Address - Street 1:950 LAKE BALDWIN LN
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32814-6651
Practice Address - Country:US
Practice Address - Phone:407-515-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-10
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 19371122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist