MEDICARE: DR. KENNETH LEROY ANDERSON III D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	DN22380	FL
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	DN 22380	FL
3	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	D12714	MN

General Provider Information

NPI Number	:	1023230539
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH LEROY ANDERSON III D.D.S.

Provider Business Mailing Address
First Line	:	7520 EXCITEMENT DR
Second Line	:
City	:	REUNION
State	:	FL
Zip	:	34747-6748
Country	:	US
Telephone Number	:	312-402-3250
Fax Number	:

Provider Business Practice Location Address
First Line	:	4372 COMMERCIAL WAY
Second Line	:
City	:	SPRING HILL
State	:	FL
Zip	:	34606-1965
Country	:	US
Telephone Number	:	352-596-6804
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	12/15/2024

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