Provider Demographics
NPI:1356697973
Name:ANDERSON FAMILY DENTAL PA
Entity type:Organization
Organization Name:ANDERSON FAMILY DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-245-1278
Mailing Address - Street 1:PO BOX 756
Mailing Address - Street 2:
Mailing Address - City:COLERAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55722-0756
Mailing Address - Country:US
Mailing Address - Phone:218-245-1278
Mailing Address - Fax:218-245-1333
Practice Address - Street 1:209 MCLEAN AVE
Practice Address - Street 2:
Practice Address - City:COLERAINE
Practice Address - State:MN
Practice Address - Zip Code:55722-0756
Practice Address - Country:US
Practice Address - Phone:218-245-1278
Practice Address - Fax:218-245-1333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-01
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN125431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty