Provider Demographics
NPI:1184896938
Name:ANDERSON ORTHODONTICS
Entity type:Organization
Organization Name:ANDERSON ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:A
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:507-665-3394
Mailing Address - Street 1:17570 HACKBERRY CT
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55347-4271
Mailing Address - Country:US
Mailing Address - Phone:952-486-7674
Mailing Address - Fax:
Practice Address - Street 1:302 VALLEY GREEN SQ
Practice Address - Street 2:
Practice Address - City:LE SUEUR
Practice Address - State:MN
Practice Address - Zip Code:56058-1943
Practice Address - Country:US
Practice Address - Phone:507-665-3394
Practice Address - Fax:507-665-4286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN9178768Medicaid