Provider Demographics
NPI:1124663067
Name:ANDERSON, BRUCE WILLIAM (DDS)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:WILLIAM
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 1:2725 FOX FARM RD
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:56187-3040
Mailing Address - Country:US
Mailing Address - Phone:507-372-2869
Mailing Address - Fax:
Practice Address - Street 1:2725 FOX FARM RD
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:MN
Practice Address - Zip Code:56187-3040
Practice Address - Country:US
Practice Address - Phone:507-372-2869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-14
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN82451223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE