Healthcare Provider Details

I. General information

NPI: 1104814003
Provider Name (Legal Business Name): ARTHUR A BRODERSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6665 CAHILL AVE
INVER GROVE HEIGHTS MN
55076-2026
US

IV. Provider business mailing address

PO BOX 2005
INVER GROVE HEIGHTS MN
55076-8005
US

V. Phone/Fax

Practice location:
  • Phone: 651-455-1247
  • Fax: 651-455-8375
Mailing address:
  • Phone: 651-455-1247
  • Fax: 651-455-8375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7757
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: