=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013033851
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANDERSON DENTAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 514-D EAST WOODROW WILSON DR.
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39216-4538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-366-1112
-----------------------------------------------------
Fax | 601-366-6092
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 11277
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39283-1277
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-366-1112
-----------------------------------------------------
Fax | 601-366-6092
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. LEON ANDERSON JR.
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 601-366-1112
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | MS2164-85
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------