Provider Demographics
NPI:1417365529
Name:BONNIE J. ANDERSON
Entity Type:Organization
Organization Name:BONNIE J. ANDERSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DENTIST
Authorized Official - Phone:701-523-5651
Mailing Address - Street 1:20 1ST AVE NW
Mailing Address - Street 2:BOX E
Mailing Address - City:BOWMAN
Mailing Address - State:ND
Mailing Address - Zip Code:58623
Mailing Address - Country:US
Mailing Address - Phone:701-523-5651
Mailing Address - Fax:701-523-5652
Practice Address - Street 1:20 1ST AVE SW
Practice Address - Street 2:BOX E
Practice Address - City:BOWMAN
Practice Address - State:ND
Practice Address - Zip Code:58623-4213
Practice Address - Country:US
Practice Address - Phone:701-523-5651
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-01
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1771122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND41045Medicaid