Provider Demographics
NPI:1356401459
Name:ANDERSON, KEITH FLETCHER (DMD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:FLETCHER
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9225 MANCHESTER RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63144-2640
Mailing Address - Country:US
Mailing Address - Phone:314-961-5866
Mailing Address - Fax:314-918-0165
Practice Address - Street 1:9225 MANCHESTER RD
Practice Address - Street 2:SUITE 202
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63144-2640
Practice Address - Country:US
Practice Address - Phone:314-961-5866
Practice Address - Fax:314-918-0165
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO014386122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist