Provider Demographics
NPI:1891178539
Name:ANDERSON, KEON (DDS)
Entity type:Individual
Prefix:
First Name:KEON
Middle Name:
Last Name:ANDERSON
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:PO BOX 732973
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-2973
Mailing Address - Country:US
Mailing Address - Phone:817-702-2450
Mailing Address - Fax:
Practice Address - Street 1:100 N LAMAR ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76196-0216
Practice Address - Country:US
Practice Address - Phone:817-702-3567
Practice Address - Fax:817-569-1421
Is Sole Proprietor?:No
Enumeration Date:2015-06-30
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX310421223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice