Healthcare Provider Details

I. General information

NPI: 1265699060
Provider Name (Legal Business Name): ALICIA PANNIER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2008
Last Update Date: 05/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 OSTERMANN DR
TURTLE LAKE WI
54889-9191
US

IV. Provider business mailing address

225 OSTERMANN DR
TURTLE LAKE WI
54889-9191
US

V. Phone/Fax

Practice location:
  • Phone: 715-641-0981
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number6752-016
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: