Provider Demographics
NPI:1013277094
Name:GULLICKSON, ALYSSA LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALYSSA
Middle Name:LYNN
Last Name:GULLICKSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MS
Other - First Name:ALYSSA
Other - Middle Name:LYNN
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23665 N LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:56334-9375
Mailing Address - Country:US
Mailing Address - Phone:320-808-4126
Mailing Address - Fax:
Practice Address - Street 1:308 BLATTNER DR
Practice Address - Street 2:SUITE A
Practice Address - City:AVON
Practice Address - State:MN
Practice Address - Zip Code:56310-4531
Practice Address - Country:US
Practice Address - Phone:320-356-7374
Practice Address - Fax:320-356-9427
Is Sole Proprietor?:No
Enumeration Date:2012-05-23
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13077122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist