Healthcare Provider Details

I. General information

NPI: 1083917363
Provider Name (Legal Business Name): ANNANDALE DENTAL CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2010
Last Update Date: 12/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

93 OAK AVE S UNIT #3
ANNANDALE MN
55302-1205
US

IV. Provider business mailing address

PO BOX 539
ANNANDALE MN
55302-0539
US

V. Phone/Fax

Practice location:
  • Phone: 320-274-2475
  • Fax: 320-274-3152
Mailing address:
  • Phone: 320-274-2475
  • Fax: 320-274-3152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberD11795
License Number StateMN

VIII. Authorized Official

Name: DR. ANTHONY DAVID HEGGE
Title or Position: OWNER/PRESIDENT
Credential: DDS
Phone: 320-274-2475