Provider Demographics
NPI:1508080615
Name:ANDERSON, STACEY FRANCIS (RDH)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:FRANCIS
Last Name:ANDERSON
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 1:2454 HIGHWAY 2
Mailing Address - Street 2:
Mailing Address - City:TWO HARBORS
Mailing Address - State:MN
Mailing Address - Zip Code:55616-3000
Mailing Address - Country:US
Mailing Address - Phone:218-206-4328
Mailing Address - Fax:
Practice Address - Street 1:2454 HIGHWAY 2
Practice Address - Street 2:
Practice Address - City:TWO HARBORS
Practice Address - State:MN
Practice Address - Zip Code:55616-3000
Practice Address - Country:US
Practice Address - Phone:218-206-4328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH5437124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN9184066OtherDORAL UCARE PROVIDER
MNDHS 709417500OtherMN DENTAL HYG