Provider Demographics
NPI:1689169401
Name:ANDERSON, KATHRYN ANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:ANN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7446 UPPER 164TH ST W
Mailing Address - Street 2:
Mailing Address - City:ROSEMOUNT
Mailing Address - State:MN
Mailing Address - Zip Code:55068-5249
Mailing Address - Country:US
Mailing Address - Phone:952-412-0528
Mailing Address - Fax:
Practice Address - Street 1:7446 UPPER 164TH ST W
Practice Address - Street 2:
Practice Address - City:ROSEMOUNT
Practice Address - State:MN
Practice Address - Zip Code:55068-5249
Practice Address - Country:US
Practice Address - Phone:952-412-0528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-25
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010227341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty