Provider Demographics
NPI:1366560302
Name:ANDERSON, JOHN (LD)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4408 PACIFIC AVE SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-1119
Mailing Address - Country:US
Mailing Address - Phone:360-438-8299
Mailing Address - Fax:360-438-1399
Practice Address - Street 1:4408 PACIFIC AVE SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1119
Practice Address - Country:US
Practice Address - Phone:360-438-8299
Practice Address - Fax:360-438-1399
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA260122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist