Healthcare Provider Details

I. General information

NPI: 1811979719
Provider Name (Legal Business Name): JONATHON HENNING ANDERSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 10/15/2018
Certification Date:
Deactivation Date: 09/24/2018
Reactivation Date: 10/13/2018

III. Provider practice location address

555 S OLD WOODWARD AVE STE 777
BIRMINGHAM MI
48009-6618
US

IV. Provider business mailing address

555 S OLD WOODWARD AVE STE 777
BIRMINGHAM MI
48009-6618
US

V. Phone/Fax

Practice location:
  • Phone: 248-647-4700
  • Fax: 248-647-4730
Mailing address:
  • Phone: 248-647-4700
  • Fax: 248-647-4730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901012981
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: