Provider Demographics
NPI:1306940770
Name:ANDERSEN, JOHN D (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 RIDGE ST
Mailing Address - Street 2:SUITE 308
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-4643
Mailing Address - Country:US
Mailing Address - Phone:712-328-8892
Mailing Address - Fax:712-328-8845
Practice Address - Street 1:13215 BIRCH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68164-5431
Practice Address - Country:US
Practice Address - Phone:402-390-0770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA72201223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0249052Medicaid
IA53949Medicare ID - Type Unspecified
IA0249052Medicaid