Healthcare Provider Details

I. General information

NPI: 1003092206
Provider Name (Legal Business Name): ANITA WHALEN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY JEAN WHALEN

II. Dates (important events)

Enumeration Date: 01/17/2008
Last Update Date: 02/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 NORTH MINNESOTA STREET
WARREN MN
56762-0093
US

IV. Provider business mailing address

620 SUMMIT AVENUE
CROOKSTON MN
56716-2799
US

V. Phone/Fax

Practice location:
  • Phone: 218-281-3441
  • Fax: 218-281-6966
Mailing address:
  • Phone: 218-281-3441
  • Fax: 218-281-6966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD8197
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: