Provider Demographics
NPI:1669554341
Name:ANDERSON, JON D (DDS)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:D
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 1:2538 UNIVERSITY DR S
Mailing Address - Street 2:STE B
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-5737
Mailing Address - Country:US
Mailing Address - Phone:701-232-1368
Mailing Address - Fax:701-232-4746
Practice Address - Street 1:2538 UNIVERSITY DR S
Practice Address - Street 2:STE B
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-5737
Practice Address - Country:US
Practice Address - Phone:701-232-1368
Practice Address - Fax:701-232-4746
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND16011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice