Provider Demographics
NPI:1114758117
Name:ANDERSON, KRISTEN ASHLEY (DMD)
Entity type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:ASHLEY
Last Name:ANDERSON
Suffix:
Gender:
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5995 S POINTE BLVD STE 109
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-3273
Mailing Address - Country:US
Mailing Address - Phone:239-286-9988
Mailing Address - Fax:239-737-2869
Practice Address - Street 1:5995 S POINTE BLVD STE 109
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3273
Practice Address - Country:US
Practice Address - Phone:239-286-9988
Practice Address - Fax:239-737-2869
Is Sole Proprietor?:No
Enumeration Date:2024-08-12
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN29443390200000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program