Healthcare Provider Details

I. General information

NPI: 1023230539
Provider Name (Legal Business Name): KENNETH LEROY ANDERSON III D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 12/15/2024
Certification Date: 12/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4372 COMMERCIAL WAY
SPRING HILL FL
34606-1965
US

IV. Provider business mailing address

7520 EXCITEMENT DR
REUNION FL
34747-6748
US

V. Phone/Fax

Practice location:
  • Phone: 352-596-6804
  • Fax:
Mailing address:
  • Phone: 312-402-3250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDN22380
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN 22380
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD12714
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: