Provider Demographics
NPI:1063508216
Name:ANDERSEN, NICOLE M (DDS)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 N LIVINGSTON STREET SUITE 301
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703
Mailing Address - Country:US
Mailing Address - Phone:608-467-8022
Mailing Address - Fax:608-222-5845
Practice Address - Street 1:10 N LIVINGSTON STREET SUITE 301
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703
Practice Address - Country:US
Practice Address - Phone:608-467-8022
Practice Address - Fax:608-222-5845
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5045-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice