Healthcare Provider Details

I. General information

NPI: 1124641303
Provider Name (Legal Business Name): MACY RUTH ANDERSON D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2020
Last Update Date: 08/16/2022
Certification Date: 08/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 N PORT WASHINGTON RD STE 201
GLENDALE WI
53217-5400
US

IV. Provider business mailing address

5150 N PORT WASHINGTON RD STE 201
GLENDALE WI
53217-5400
US

V. Phone/Fax

Practice location:
  • Phone: 414-964-8850
  • Fax:
Mailing address:
  • Phone: 414-964-8850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1002304
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: