MEDICARE: DR. ELIZABETH ANN AMUNDSON D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	D12992	MN
2	1223G0001X	General Practice Dentistry	6409-15	WI

General Provider Information

NPI Number	:	1508094947
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELIZABETH ANN AMUNDSON D.D.S.

Provider Business Mailing Address
First Line	:	2306 S. BROADWAY STREET S
Second Line	:	SUITE 4
City	:	ALEXANDRIA
State	:	MN
Zip	:	56308-3461
Country	:	US
Telephone Number	:	320-762-5216
Fax Number	:	320-762-5694

Provider Business Practice Location Address
First Line	:	2306 S. BROADWAY STREET S
Second Line	:	SUITE 4
City	:	ALEXANDRIA
State	:	MN
Zip	:	56308-3461
Country	:	US
Telephone Number	:	320-762-5216
Fax Number	:	320-762-5694

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2009
Last Update Date	:	10/03/2013

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