Provider Demographics
NPI:1124641303
Name:ANDERSON, MACY RUTH (DDS)
Entity type:Individual
Prefix:DR
First Name:MACY
Middle Name:RUTH
Last Name:ANDERSON
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 1:5150 N PORT WASHINGTON RD STE 201
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-5400
Mailing Address - Country:US
Mailing Address - Phone:414-964-8850
Mailing Address - Fax:
Practice Address - Street 1:5150 N PORT WASHINGTON RD STE 201
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-5400
Practice Address - Country:US
Practice Address - Phone:414-964-8850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-22
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI10023041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program