Provider Demographics
NPI:1275504292
Name:ANDERSON, RYAN JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:JAMES
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13870 52ND AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446
Mailing Address - Country:US
Mailing Address - Phone:612-760-0924
Mailing Address - Fax:
Practice Address - Street 1:6120 BROOKLYN BLVD, STE 201
Practice Address - Street 2:HERITAGE DENTAL
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55427
Practice Address - Country:US
Practice Address - Phone:763-537-6070
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11662122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist