Provider Demographics
NPI:1992987119
Name:ANDERSON, JACQUELINE J (DDS)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:J
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 OTTAWA BEACH ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-2567
Mailing Address - Country:US
Mailing Address - Phone:616-399-9520
Mailing Address - Fax:616-399-0945
Practice Address - Street 1:1121 OTTAWA BEACH ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-2567
Practice Address - Country:US
Practice Address - Phone:616-399-9520
Practice Address - Fax:616-399-0945
Is Sole Proprietor?:No
Enumeration Date:2007-11-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901015310122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist