Provider Demographics
NPI:1194070110
Name:ANDERSON, JAY ROSAMOND (DMD)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:ROSAMOND
Last Name:ANDERSON
Suffix:
Gender:M
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:P.O. BOX 1559
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93302
Mailing Address - Country:US
Mailing Address - Phone:661-635-3050
Mailing Address - Fax:661-635-3070
Practice Address - Street 1:1125 E CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93307-1201
Practice Address - Country:US
Practice Address - Phone:661-632-2144
Practice Address - Fax:661-328-4211
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2017-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1856087122300000X
ORDF0027122300000X
KY4887122300000X
CA1013911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPENDINGMedicaid