Provider Demographics
NPI:1750465761
Name:ANDERSON, JOHN AUTHUR (DMD MS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:AUTHUR
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DMD MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2894 S 8TH ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-4462
Mailing Address - Country:US
Mailing Address - Phone:904-261-0022
Mailing Address - Fax:904-261-6289
Practice Address - Street 1:2894 S 8TH ST
Practice Address - Street 2:SUITE 3
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4462
Practice Address - Country:US
Practice Address - Phone:904-261-0022
Practice Address - Fax:904-261-6289
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN90651223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics