Provider Demographics
NPI:1841371457
Name:ANDERSON, BRYAN A (DDS)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:A
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 1:104 2ND AVE SE
Mailing Address - Street 2:
Mailing Address - City:WASECA
Mailing Address - State:MN
Mailing Address - Zip Code:56093-3041
Mailing Address - Country:US
Mailing Address - Phone:507-835-4280
Mailing Address - Fax:
Practice Address - Street 1:104 2ND AVE SE
Practice Address - Street 2:
Practice Address - City:WASECA
Practice Address - State:MN
Practice Address - Zip Code:56093-3041
Practice Address - Country:US
Practice Address - Phone:507-835-4280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN092841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice