Provider Demographics
NPI:1336630128
Name:COURTEMANCHE, ANNIE
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:COURTEMANCHE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6499 E BROAD ST STE 110
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-6506
Mailing Address - Country:US
Mailing Address - Phone:614-868-9804
Mailing Address - Fax:
Practice Address - Street 1:6499 E BROAD ST STE 110
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-6506
Practice Address - Country:US
Practice Address - Phone:614-868-9804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0254481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice