Healthcare Provider Details

I. General information

NPI: 1013277094
Provider Name (Legal Business Name): ALYSSA LYNN GULLICKSON D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. ALYSSA LYNN BROWN

II. Dates (important events)

Enumeration Date: 05/23/2012
Last Update Date: 05/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 BLATTNER DR SUITE A
AVON MN
56310-4531
US

IV. Provider business mailing address

23665 N LAKESHORE DR
GLENWOOD MN
56334-9375
US

V. Phone/Fax

Practice location:
  • Phone: 320-356-7374
  • Fax: 320-356-9427
Mailing address:
  • Phone: 320-808-4126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD13077
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: