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General NPI Number Information
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NPI Number | 1508094947
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Entity Type | Individual
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Provider Name | ELIZABETH ANN AMUNDSON D.D.S.
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Gender | Female
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Dates
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Enumeration Date | 06/24/2009
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Last Update Date | 10/03/2013
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Provider Practice Location Address
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Address Line | 2306 S. BROADWAY STREET S SUITE 4
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City | ALEXANDRIA
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State | MN
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Zip | 56308-3461
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Country | US
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Telephone | 320-762-5216
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Fax | 320-762-5694
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Provider Business Mailing Address
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Address Line | 2306 S. BROADWAY STREET S SUITE 4
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City | ALEXANDRIA
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State | MN
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Zip | 56308-3461
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Country | US
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Telephone | 320-762-5216
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Fax | 320-762-5694
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D12992
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 6409-15
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License Number State | WI
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