Healthcare Provider Details

I. General information

NPI: 1215278676
Provider Name (Legal Business Name): ANDERSON & BREDING DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2013
Last Update Date: 09/25/2020
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4521 38TH AVE. S.
FARGO ND
58104
US

IV. Provider business mailing address

4521 38TH AVE. S.
FARGO ND
58104
US

V. Phone/Fax

Practice location:
  • Phone: 701-232-1368
  • Fax: 701-232-4746
Mailing address:
  • Phone: 701-232-1368
  • Fax: 701-232-4746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberND1601
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberND2045
License Number StateND

VIII. Authorized Official

Name: DR. BRADLEY JON ANDERSON
Title or Position: CO-OWNER
Credential: DDS
Phone: 701-232-1368