Provider Demographics
NPI:1104837921
Name:ANDERSON, THANE B (DDS)
Entity Type:Individual
Prefix:DR
First Name:THANE
Middle Name:B
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 1:1520 VERNON ST
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589-2260
Mailing Address - Country:US
Mailing Address - Phone:608-873-3213
Mailing Address - Fax:608-873-7254
Practice Address - Street 1:1520 VERNON ST
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589-2260
Practice Address - Country:US
Practice Address - Phone:608-873-3213
Practice Address - Fax:608-873-7254
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4812W1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice