Provider Demographics
NPI:1699886457
Name:ANDERSON, EDWARD ANDREW (DDS)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:ANDREW
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 1:302 2ND AVE SW
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58401-4157
Mailing Address - Country:US
Mailing Address - Phone:701-252-1661
Mailing Address - Fax:701-251-9128
Practice Address - Street 1:302 2ND AVE SW
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-4157
Practice Address - Country:US
Practice Address - Phone:701-252-1661
Practice Address - Fax:701-251-9128
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND15591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1559OtherSTATE LICENSE #
ND40612Medicaid