Provider Demographics
NPI:1881187862
Name:AGNES, ALISON ANN (DDS)
Entity Type:Individual
Prefix:
First Name:ALISON
Middle Name:ANN
Last Name:AGNES
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 1:1011 SADDLE CREEK LN
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-1934
Mailing Address - Country:US
Mailing Address - Phone:815-382-3210
Mailing Address - Fax:
Practice Address - Street 1:2388 S ONEIDA ST
Practice Address - Street 2:
Practice Address - City:ASHWAUBENON
Practice Address - State:WI
Practice Address - Zip Code:54304-5256
Practice Address - Country:US
Practice Address - Phone:920-785-5130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001866-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist