Provider Demographics
NPI:1184872137
Name:ANDERSON FAMILY DENTISTRY
Entity type:Organization
Organization Name:ANDERSON FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:R
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-295-0515
Mailing Address - Street 1:810 S. WAUKEGAN RD.
Mailing Address - Street 2:SUITE 106
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045
Mailing Address - Country:US
Mailing Address - Phone:847-295-0515
Mailing Address - Fax:847-234-0048
Practice Address - Street 1:810 S. WAUKEGAN RD.
Practice Address - Street 2:SUITE 106
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045
Practice Address - Country:US
Practice Address - Phone:847-295-0515
Practice Address - Fax:847-234-0048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL01919692122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty