Provider Demographics
NPI:1780123216
Name:ANDERSON, JOHN FRED JR (DDS, MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:FRED
Last Name:ANDERSON
Suffix:JR
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17093 PALISADES CIR
Mailing Address - Street 2:
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-2139
Mailing Address - Country:US
Mailing Address - Phone:310-717-6456
Mailing Address - Fax:
Practice Address - Street 1:17093 PALISADES CIR
Practice Address - Street 2:
Practice Address - City:PACIFIC PALISADES
Practice Address - State:CA
Practice Address - Zip Code:90272-2139
Practice Address - Country:US
Practice Address - Phone:310-717-6456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-16
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1086471223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery