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General NPI Number Information
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NPI Number | 1356697973
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Entity Type | Organization
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Legal Business Name | ANDERSON FAMILY DENTAL PA
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Dates
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Enumeration Date | 08/01/2012
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Last Update Date | 08/01/2012
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Provider Practice Location Address
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Address Line | 209 MCLEAN AVE
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City | COLERAINE
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State | MN
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Zip | 55722-0756
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Country | US
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Telephone | 218-245-1278
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Fax | 218-245-1333
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Provider Business Mailing Address
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Address Line | PO BOX 756
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City | COLERAINE
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State | MN
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Zip | 55722-0756
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Country | US
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Telephone | 218-245-1278
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Fax | 218-245-1333
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Authorized Official
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Title or Position | OWNER
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Name | JORDAN DAVID ANDERSON
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Credential | DDS
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Telephone | 218-245-1278
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 12543
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License Number State | MN
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