Provider Demographics
NPI:1245420280
Name:DR. THANE B. ANDERSON, DDS, LLC
Entity Type:Organization
Organization Name:DR. THANE B. ANDERSON, DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THANE
Authorized Official - Middle Name:B
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-873-3213
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4812W261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI=========OtherTAX ID NUMBER