Provider Demographics
NPI:1811979719
Name:ANDERSON, JONATHON HENNING (DDS)
Entity type:Individual
Prefix:
First Name:JONATHON
Middle Name:HENNING
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 1:555 S OLD WOODWARD AVE STE 777
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6618
Mailing Address - Country:US
Mailing Address - Phone:248-647-4700
Mailing Address - Fax:248-647-4730
Practice Address - Street 1:555 S OLD WOODWARD AVE STE 777
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6618
Practice Address - Country:US
Practice Address - Phone:248-647-4700
Practice Address - Fax:248-647-4730
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2018-10-15
Deactivation Date:2018-09-24
Deactivation Code:
Reactivation Date:2018-10-13
Provider Licenses
StateLicense IDTaxonomies
MI29010129811223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2990516Medicaid
MI4067429Medicaid
MI970F31085OtherBCBSM
MIJA012981OtherLICENSE NUMBER
MI2990516Medicaid