Healthcare Provider Details

I. General information

NPI: 1184896938
Provider Name (Legal Business Name): ANDERSON ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2008
Last Update Date: 04/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 VALLEY GREEN SQ
LE SUEUR MN
56058-1943
US

IV. Provider business mailing address

17570 HACKBERRY CT
EDEN PRAIRIE MN
55347-4271
US

V. Phone/Fax

Practice location:
  • Phone: 507-665-3394
  • Fax: 507-665-4286
Mailing address:
  • Phone: 952-486-7674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JASON A ANDERSON
Title or Position: ORTHODONTIST
Credential: DDS MS
Phone: 507-665-3394