Kenneth R Anderson Jr., D.D.S
Individual provider Active NPI Dentist · Lake Forest, IL
NPI 1992003370 · NPPES record last updated Mar 8, 2011
Key facts
- NPI
- 1992003370
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Dentist 122300000X
- License
- 019019692 (IL)
- Practice address
- 810 S Waukegan Rd
Lake Forest, IL 60045-2693 - Phone
- (847) 295-0515
- NPI assigned
- Mar 8, 2011
- 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 May 23, 2016 through May 23, 2028
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 019019692 | IL | MD | Dentist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Anderson Family Dentistry | Dentist | Past | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 019019692 | IL | Yes |
Addresses
Primary practice location
810 S Waukegan Rd
Lake Forest, IL 60045-2693
Mailing address
810 S Waukegan Rd
Lake Forest, IL 60045-2693
Phone (847) 295-0515
Other providers in Lake Forest, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 8, 2011. 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.