Provider Demographics
NPI:1285731679
Name:ANDERSON, JEAN ELLEN (RDH)
Entity type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:ELLEN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9098 JENSEN AVE SOUTH
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016
Mailing Address - Country:US
Mailing Address - Phone:651-459-4632
Mailing Address - Fax:
Practice Address - Street 1:1789 WOODLANE DRIVE
Practice Address - Street 2:SUITE D
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125
Practice Address - Country:US
Practice Address - Phone:651-738-1284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH5261124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist