Provider Demographics
NPI:1407043417
Name:ANDERSEN, THOMAS (DDS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:ANDERSEN
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 1:14265 SUNRISE AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-1122
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14265 SUNRISE AVE
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-1122
Practice Address - Country:US
Practice Address - Phone:262-373-1135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-03
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4001323122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist