Provider Demographics
NPI:1467934851
Name:GENDRON, ALICIA NICOLE (RDH)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:NICOLE
Last Name:GENDRON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 S PECK AVE
Mailing Address - Street 2:
Mailing Address - City:PESHTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54157-1511
Mailing Address - Country:US
Mailing Address - Phone:906-285-3545
Mailing Address - Fax:
Practice Address - Street 1:2280 W MASON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-4707
Practice Address - Country:US
Practice Address - Phone:920-321-3501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1003347-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist