Provider Demographics
NPI:1104814003
Name:BRODERSON, ARTHUR A (DDS)
Entity type:Individual
Prefix:DR
First Name:ARTHUR
Middle Name:A
Last Name:BRODERSON
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:PO BOX 2005
Mailing Address - Street 2:
Mailing Address - City:INVER GROVE HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55076-8005
Mailing Address - Country:US
Mailing Address - Phone:651-455-1247
Mailing Address - Fax:651-455-8375
Practice Address - Street 1:6665 CAHILL AVE
Practice Address - Street 2:
Practice Address - City:INVER GROVE HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55076-2026
Practice Address - Country:US
Practice Address - Phone:651-455-1247
Practice Address - Fax:651-455-8375
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN77571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice