Provider Demographics
NPI:1902443625
Name:KEVIN ANDERSON DMD PLCC
Entity Type:Organization
Organization Name:KEVIN ANDERSON DMD PLCC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:651-731-2141
Mailing Address - Street 1:1075 HADLEY AVE N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-5951
Mailing Address - Country:US
Mailing Address - Phone:651-731-2141
Mailing Address - Fax:651-731-3601
Practice Address - Street 1:1075 HADLEY AVE N
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-5951
Practice Address - Country:US
Practice Address - Phone:651-731-2141
Practice Address - Fax:651-731-3601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-01
Last Update Date:2019-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental