Healthcare Provider Details

I. General information

NPI: 1710052691
Provider Name (Legal Business Name): THOMAS W. ANDERSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2006
Last Update Date: 12/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11237 FOLEY BLVD. NW
COON RAPIDS MN
55448
US

IV. Provider business mailing address

11237 FOLEY BLVD. NW
COON RAPIDS MN
55448
US

V. Phone/Fax

Practice location:
  • Phone: 763-757-3120
  • Fax: 763-757-5161
Mailing address:
  • Phone: 763-757-3120
  • Fax: 763-757-5161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7054
License Number StateMN

VIII. Authorized Official

Name: MR. RICHARD GERARD BATTAGLIA
Title or Position: OWNER/DENTIST
Credential: D.D.S.
Phone: 763-757-1234