Provider Demographics
NPI:1922571884
Name:FANDRE, ERIN KAYE (RDH)
Entity Type:Individual
Prefix:MRS
First Name:ERIN
Middle Name:KAYE
Last Name:FANDRE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:MS
Other - First Name:ERIN
Other - Middle Name:KAYE
Other - Last Name:MARCUSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:111 W JACKSON STREET
Mailing Address - Street 2:THIRD FLOOR
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54495-3338
Mailing Address - Country:US
Mailing Address - Phone:920-639-7384
Mailing Address - Fax:
Practice Address - Street 1:111 W JACKSON STREET
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54495-3338
Practice Address - Country:US
Practice Address - Phone:920-639-7384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-03
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002546-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist