Provider Demographics
NPI:1568678985
Name:ANDERSON, COURTNEY ALLISON (DDS)
Entity Type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:ALLISON
Last Name:ANDERSON
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 1:1903 S 6TH ST STE 4
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-4599
Mailing Address - Country:US
Mailing Address - Phone:920-965-4055
Mailing Address - Fax:218-829-1728
Practice Address - Street 1:1903 S 6TH ST STE 4
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-4599
Practice Address - Country:US
Practice Address - Phone:218-829-1728
Practice Address - Fax:218-829-1729
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND116731223S0112X
WI6669204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI714600076Medicare PIN
WI076500328Medicare PIN