Healthcare Provider Details

I. General information

NPI: 1891716445
Provider Name (Legal Business Name): JASON A ANDERSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/09/2007
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

302 VALLEY GREEN SQ
LE SUEUR MN
56058-1943
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number11588
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: