Provider Demographics
NPI:1679884498
Name:MINNEMA, ANNA LAURA (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANNA
Middle Name:LAURA
Last Name:MINNEMA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:ANNA
Other - Middle Name:LAURA
Other - Last Name:KENNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:501 E LAKE ST
Mailing Address - Street 2:
Mailing Address - City:HORICON
Mailing Address - State:WI
Mailing Address - Zip Code:53032-1264
Mailing Address - Country:US
Mailing Address - Phone:920-485-4831
Mailing Address - Fax:920-485-6780
Practice Address - Street 1:501 E LAKE ST
Practice Address - Street 2:
Practice Address - City:HORICON
Practice Address - State:WI
Practice Address - Zip Code:53032
Practice Address - Country:US
Practice Address - Phone:920-485-4831
Practice Address - Fax:920-485-6780
Is Sole Proprietor?:No
Enumeration Date:2010-06-25
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6539-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice