Basic Information
| Provider Information | |||||||||
| NPI: | 1306940770 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSEN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 RIDGE ST | ||||||||
| Address2: | SUITE 308 | ||||||||
| City: | COUNCIL BLUFFS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 515034643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7123288892 | ||||||||
| FaxNumber: | 7123288845 | ||||||||
| Practice Location | |||||||||
| Address1: | 13215 BIRCH ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681645431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023900770 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2006 | ||||||||
| LastUpdateDate: | 12/22/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | 7220 | IA | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0249052 | 05 | IA | MEDICAID |