MEDICARE: JONATHAN ANDERSON DDS PC

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	122300000X	Dentist

General Provider Information

NPI Number	:	1366986598
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JONATHAN ANDERSON DDS PC

Provider Business Mailing Address
First Line	:	4360 BOARDWALK DR
Second Line	:	STE 100
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-5932
Country	:	US
Telephone Number	:	970-226-2920
Fax Number	:

Provider Business Practice Location Address
First Line	:	4745 BOARDWALK DR STE D102
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-3773
Country	:	US
Telephone Number	:	970-552-7874
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JONATHAN ANDERSON
Credential	:
Telephone Number	:	970-552-7874

Provider Enumeration Date	:	12/07/2016
Last Update Date	:	02/12/2025

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