MEDICARE: ANDERSON DENTAL P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1063019537
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANDERSON DENTAL P.C.

Provider Business Mailing Address
First Line	:	1219 SAINT JOSEPH ST
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57701-2669
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1219 SAINT JOSEPH ST
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57701-2669
Country	:	US
Telephone Number	:	605-721-1219
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DOCTOR
Name	:	KARL ANDERSON
Credential	:
Telephone Number	:	605-721-1219

Provider Enumeration Date	:	10/07/2020
Last Update Date	:	10/07/2020

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