Provider Demographics
NPI:1518041797
Name:ANDERSON, WALLACE JAY (DDS)
Entity type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:JAY
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8833 80TH STREET N
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082
Mailing Address - Country:US
Mailing Address - Phone:651-653-6558
Mailing Address - Fax:
Practice Address - Street 1:1260 COUNTY ROAD E WEST
Practice Address - Street 2:
Practice Address - City:ARDEN HILLS
Practice Address - State:MN
Practice Address - Zip Code:55112-3737
Practice Address - Country:US
Practice Address - Phone:651-639-0452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7786122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist