Provider Demographics
NPI:1861498933
Name:ANDERSON, RICHARD J (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:J
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 1:3922 W 50TH ST
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55424-1255
Mailing Address - Country:US
Mailing Address - Phone:952-926-0284
Mailing Address - Fax:952-926-8723
Practice Address - Street 1:3922 W 50TH ST
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55424-1255
Practice Address - Country:US
Practice Address - Phone:952-926-0284
Practice Address - Fax:952-926-8723
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN87881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN00370ANOtherBLUE CROSS BLUE SHIELD
MNU97294Medicare UPIN