Provider Demographics
NPI:1760655765
Name:ANDERSON, THOMAS WARREN (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:WARREN
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 1:11237 FOLEY BLVD NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-3389
Mailing Address - Country:US
Mailing Address - Phone:763-757-1234
Mailing Address - Fax:
Practice Address - Street 1:11237 FOLEY BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-3389
Practice Address - Country:US
Practice Address - Phone:763-757-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND7054122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist