Healthcare Provider Details

I. General information

NPI: 1821296146
Provider Name (Legal Business Name): DANIEL B ANDERSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2007
Last Update Date: 07/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 S BAY SHORE DR
SISTER BAY WI
54234
US

IV. Provider business mailing address

10589 S HIGHLAND RD STE 4
SISTER BAY WI
54234
US

V. Phone/Fax

Practice location:
  • Phone: 920-854-5200
  • Fax: 920-854-7601
Mailing address:
  • Phone: 920-854-5200
  • Fax: 920-854-7601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4454
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: