Provider Demographics
NPI:1699902023
Name:ANDERSON, THERESA LORENE (RDH)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:LORENE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4905 PALOMINO LN
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043-3518
Mailing Address - Country:US
Mailing Address - Phone:972-240-3014
Mailing Address - Fax:
Practice Address - Street 1:1927 FAITHON P LUCAS SR BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75181-1696
Practice Address - Country:US
Practice Address - Phone:469-341-3888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-11
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13282124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist