Provider Demographics
NPI:1669445805
Name:ANDERSON, JUSTIN ROY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:ROY
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 1:831 VERMONT ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044-2665
Mailing Address - Country:US
Mailing Address - Phone:785-843-6060
Mailing Address - Fax:785-843-4335
Practice Address - Street 1:831 VERMONT ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-2665
Practice Address - Country:US
Practice Address - Phone:785-843-6060
Practice Address - Fax:785-843-4335
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS7194122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO29807017OtherBC/BS OF KANSAS CITY
KS116686OtherBC/BS OF KS