Provider Demographics
NPI:1659449098
Name:ANDERSON, PAUL DANIEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:DANIEL
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 1:399 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:MAHTOMEDI
Mailing Address - State:MN
Mailing Address - Zip Code:55115
Mailing Address - Country:US
Mailing Address - Phone:651-653-5283
Mailing Address - Fax:
Practice Address - Street 1:4778 BANNING AVE
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3264
Practice Address - Country:US
Practice Address - Phone:651-426-8998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9267122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist