Provider Demographics
NPI:1932118759
Name:ANDERSON, KATHLEEN I (DO)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:I
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1521 N HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501-2372
Mailing Address - Country:US
Mailing Address - Phone:605-224-6111
Mailing Address - Fax:605-224-0687
Practice Address - Street 1:1521 N HARRISON AVE
Practice Address - Street 2:
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501-2372
Practice Address - Country:US
Practice Address - Phone:605-224-6111
Practice Address - Fax:605-224-0687
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM539122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist