Provider Demographics
NPI:1578874426
Name:EDWARDS, ALISSA (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALISSA
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:ALISSA
Other - Middle Name:
Other - Last Name:TOMALAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4866 W CORSICAN PINE DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-6509
Mailing Address - Country:US
Mailing Address - Phone:414-975-2240
Mailing Address - Fax:
Practice Address - Street 1:1155 WITTMANN DR
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-3607
Practice Address - Country:US
Practice Address - Phone:920-725-5584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-25
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6542-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist