Provider Demographics
NPI:1003092206
Name:WHALEN, ANITA (DDS)
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:WHALEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:JEAN
Other - Last Name:WHALEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:620 SUMMIT AVENUE
Mailing Address - Street 2:
Mailing Address - City:CROOKSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56716-2799
Mailing Address - Country:US
Mailing Address - Phone:218-281-3441
Mailing Address - Fax:218-281-6966
Practice Address - Street 1:508 NORTH MINNESOTA STREET
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MN
Practice Address - Zip Code:56762-0093
Practice Address - Country:US
Practice Address - Phone:218-281-3441
Practice Address - Fax:218-281-6966
Is Sole Proprietor?:No
Enumeration Date:2008-01-17
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND81971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN531018100Medicaid