MEDICARE: DR. WALLACE JAY ANDERSON DDS

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	7786	MN

General Provider Information

NPI Number	:	1518041797
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WALLACE JAY ANDERSON DDS

Provider Business Mailing Address
First Line	:	8833 80TH STREET N
Second Line	:
City	:	STILLWATER
State	:	MN
Zip	:	55082
Country	:	US
Telephone Number	:	651-653-6558
Fax Number	:

Provider Business Practice Location Address
First Line	:	1260 COUNTY ROAD E WEST
Second Line	:
City	:	ARDEN HILLS
State	:	MN
Zip	:	55112-3737
Country	:	US
Telephone Number	:	651-639-0452
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	07/08/2007

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