Provider Demographics
NPI:1487337937
Name:ANDERSON, KIERESTEN R (RDHAP)
Entity type:Individual
Prefix:MRS
First Name:KIERESTEN
Middle Name:R
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:459 S CHINA LAKE BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-4669
Mailing Address - Country:US
Mailing Address - Phone:760-608-4102
Mailing Address - Fax:
Practice Address - Street 1:459 S CHINA LAKE BLVD STE D
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-4669
Practice Address - Country:US
Practice Address - Phone:760-428-8837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-10
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1001125K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125K00000XDental ProvidersAdvanced Practice Dental Therapist