Provider Demographics
NPI:1083917363
Name:ANNANDALE DENTAL CLINIC PC
Entity Type:Organization
Organization Name:ANNANDALE DENTAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:HEGGE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:320-274-2475
Mailing Address - Street 1:PO BOX 539
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55302-0539
Mailing Address - Country:US
Mailing Address - Phone:320-274-2475
Mailing Address - Fax:320-274-3152
Practice Address - Street 1:93 OAK AVE S
Practice Address - Street 2:UNIT #3
Practice Address - City:ANNANDALE
Practice Address - State:MN
Practice Address - Zip Code:55302-1205
Practice Address - Country:US
Practice Address - Phone:320-274-2475
Practice Address - Fax:320-274-3152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-08
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11795261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental