Provider Demographics
NPI:1720572647
Name:KEITH ANDERSON ORTHODONTICS PLLC
Entity Type:Organization
Organization Name:KEITH ANDERSON ORTHODONTICS PLLC
Other - Org Name:ANDERSON ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-310-1871
Mailing Address - Street 1:416 GLENN CT
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-8678
Mailing Address - Country:US
Mailing Address - Phone:801-310-1871
Mailing Address - Fax:
Practice Address - Street 1:310 NW JOHN JONES DR
Practice Address - Street 2:SUITE 108
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028
Practice Address - Country:US
Practice Address - Phone:817-989-6000
Practice Address - Fax:817-484-6025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX337761223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty