Provider Demographics
NPI:1508094947
Name:AMUNDSON, ELIZABETH ANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:ANN
Last Name:AMUNDSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2306 S. BROADWAY STREET S
Mailing Address - Street 2:SUITE 4
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-3461
Mailing Address - Country:US
Mailing Address - Phone:320-762-5216
Mailing Address - Fax:320-762-5694
Practice Address - Street 1:2306 S. BROADWAY STREET S
Practice Address - Street 2:SUITE 4
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-3461
Practice Address - Country:US
Practice Address - Phone:320-762-5216
Practice Address - Fax:320-762-5694
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12992122300000X
WI6409-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice