Provider Demographics
NPI:1336216647
Name:AXE, JIM ANDERSON (DDS)
Entity type:Individual
Prefix:DR
First Name:JIM
Middle Name:ANDERSON
Last Name:AXE
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 1:4501 50TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79414-3613
Mailing Address - Country:US
Mailing Address - Phone:806-799-0034
Mailing Address - Fax:806-771-0731
Practice Address - Street 1:4501 50TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79414-3613
Practice Address - Country:US
Practice Address - Phone:806-799-0034
Practice Address - Fax:806-771-0731
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX100221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice