John Fred Anderson Jr., DDS, MD
Individual provider Active NPI Oral and Maxillofacial Surgery (Dentist) · Pacific Palisades, CA
NPI 1780123216 · NPPES record last updated Jul 19, 2023
Key facts
- NPI
- 1780123216
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Oral and Maxillofacial Surgery (Dentist) 1223S0112X
- License
- DDS108647 (CA)
- Practice address
- 17093 Palisades Cir
Pacific Palisades, CA 90272-2139 - Phone
- (310) 717-6456
- NPI assigned
- Feb 16, 2017
- Sex
- Male
- Sole proprietor
- Yes
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
- Opted out of Medicare
- Yes, effective Mar 20, 2026 through Mar 20, 2028
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| DDS108647 | CA | MD | Oral and Maxillofacial Surgery (Dentist) |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| John F Anderson Jr DDS MD a Professional Dental Corporation | Current | Accepting new patients |
Locations
1301 20th St
Ste 400
Santa Monica, CA 90404
Phone (310) 453-5330
Interoperability endpoints
- janderson17801@uihealth.direct-ci.com
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Oral and Maxillofacial Surgery (Dentist) | 1223S0112X | DDS108647 | CA | Yes |
Addresses
Primary practice location
17093 Palisades Cir
Pacific Palisades, CA 90272-2139
Mailing address
17093 Palisades Cir
Pacific Palisades, CA 90272-2139
Phone (310) 717-6456
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All providers in Pacific Palisades, CA · Oral and Maxillofacial Surgery (Dentist) in California
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 19, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Opt Out Affidavits (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.