Healthcare Provider Details

I. General information

NPI: 1790040921
Provider Name (Legal Business Name): ANDREW JAMES RASMUSSEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2012
Last Update Date: 01/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5337 W GRANDE MARKET DR
APPLETON WI
54913-8442
US

IV. Provider business mailing address

1511 FERNANDO DR
DE PERE WI
54115-9052
US

V. Phone/Fax

Practice location:
  • Phone: 920-731-7445
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number688415
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: