Provider Demographics
NPI:1760043202
Name:ANDERSON, CRAIG W (DMD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:W
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 SELBY AVE APT 416
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-6598
Mailing Address - Country:US
Mailing Address - Phone:864-380-0540
Mailing Address - Fax:
Practice Address - Street 1:515 DELAWARE ST SE # 7-174
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0357
Practice Address - Country:US
Practice Address - Phone:612-624-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14275122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist