Provider Demographics
NPI:1730253428
Name:ANDERSON, GREGORY A (DDS)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:GREG
Other - Middle Name:A
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 1127
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58802-1127
Mailing Address - Country:US
Mailing Address - Phone:701-577-2261
Mailing Address - Fax:
Practice Address - Street 1:501 MAIN ST
Practice Address - Street 2:SUITE 4
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-5327
Practice Address - Country:US
Practice Address - Phone:701-577-2261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND16821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1682OtherSTATE LICENSE NUMBER
ND40846Medicaid