Provider Demographics
NPI:1801209101
Name:SEVERSON, VICTORIA ANN (DDS)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ANN
Last Name:SEVERSON
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 1:501 W COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-3904
Mailing Address - Country:US
Mailing Address - Phone:218-855-8244
Mailing Address - Fax:218-855-8270
Practice Address - Street 1:501 W COLLEGE DR
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-3904
Practice Address - Country:US
Practice Address - Phone:218-855-8244
Practice Address - Fax:218-855-8270
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13376122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist