Provider Demographics
NPI:1548926876
Name:DR RICHARD J ANDERSON DDS PA
Entity type:Organization
Organization Name:DR RICHARD J ANDERSON DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-926-0284
Mailing Address - Street 1:3925 W 50TH ST STE 104
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55424-1262
Mailing Address - Country:US
Mailing Address - Phone:952-926-0284
Mailing Address - Fax:952-926-8723
Practice Address - Street 1:3925 W 50TH ST STE 104
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55424-1262
Practice Address - Country:US
Practice Address - Phone:952-926-0284
Practice Address - Fax:952-926-8723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-10
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND8788OtherLICENSE