Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0106X | Oral and Maxillofacial Pathology | DDS8053 | TN |
NPI | 1245316017 |
---|---|
Provider Name | Dr. Kenneth Mark Anderson |
First Address | Memphis, TN 38163-2110 |
Second Address | Memphis, TN 38163-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/10/2006 |
Last Update Date | 05/09/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
4075323 | BCBS (01) | TN |
U99478 | (02) | TN |