Russell G. Anderson Jr., D.M.D.
Individual provider Active NPI General Practice Dentistry · Kennesaw, GA
NPI 1811068620 · NPPES record last updated Jul 8, 2007
Key facts
- NPI
- 1811068620
- Entity type
- Individual (NPI type 1)
- Primary specialty
- General Practice Dentistry 1223G0001X
- License
- 011457 (GA)
- Practice address
- 1415 Wooten Lake Rd NW
Suite 300
Kennesaw, GA 30144-1350 - Phone
- (770) 419-2535
- Fax
- (770) 419-0030
- NPI assigned
- Nov 13, 2006
- Sex
- Male
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Previously, effective Sep 6, 2018 through Sep 6, 2026
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 011457 | GA | MD | General Practice Dentistry |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 011457 | GA | Yes |
Addresses
Primary practice location
1415 Wooten Lake Rd NW
Suite 300
Kennesaw, GA 30144-1350
Mailing address
1415 Wooten Lake Rd NW
Suite 300
Kennesaw, GA 30144-1350
Phone (770) 419-2535
Other providers in Kennesaw, GA
- Elizabeth Lynn Amodeo
- Amoena USA Corporation
- Gloria B Amu
- Amy Hamilton
- Analia Home Care HME
- Philomene Andre I
- Marian Roberts Andrews
- Seychelle Violet Andronico
- Telita Anthony
- Anastasia Anugerah
All providers in Kennesaw, GA · General Practice Dentistry in Georgia
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 8, 2007. 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.
- Opt Out Affidavits (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.