Provider Demographics
NPI:1104117456
Name:ANDERSON, TIMOTHY ALWORTH (DDS)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:ALWORTH
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 1:1362 PRESTON LN
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-7071
Mailing Address - Country:US
Mailing Address - Phone:612-619-0917
Mailing Address - Fax:
Practice Address - Street 1:2059 ROBERT ST S
Practice Address - Street 2:
Practice Address - City:WEST ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-3924
Practice Address - Country:US
Practice Address - Phone:651-457-9633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-20
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13133122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist