Provider Demographics
NPI:1760618110
Name:ANDERSON, AMMON L (DDS)
Entity Type:Individual
Prefix:DR
First Name:AMMON
Middle Name:L
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 1:2910 HAMILTON BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104-2423
Mailing Address - Country:US
Mailing Address - Phone:712-255-8017
Mailing Address - Fax:
Practice Address - Street 1:2910 HAMILTON BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104-2423
Practice Address - Country:US
Practice Address - Phone:712-255-8017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-29
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6543122300000X
WY1127122300000X
IA086171223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist