Provider Demographics
NPI:1538237052
Name:ANDERSON, EDWIN WALTER JR (DDS)
Entity type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:WALTER
Last Name:ANDERSON
Suffix:JR
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 1:415 SOUTH STATE STREET
Mailing Address - Street 2:
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-2049
Mailing Address - Country:US
Mailing Address - Phone:231-296-3571
Mailing Address - Fax:231-796-2211
Practice Address - Street 1:415 SOUTH STATE STREET
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-2049
Practice Address - Country:US
Practice Address - Phone:231-296-3571
Practice Address - Fax:231-796-2211
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010101021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID101020OtherBCBS
MI4054912Medicaid
MI652165OtherUNITED CONCORDIA
MI4054912Medicaid