Provider Demographics
NPI:1538255385
Name:ANDERSON, CAROL LYNN (DDS)
Entity type:Individual
Prefix:DR
First Name:CAROL
Middle Name:LYNN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:56223-1301
Mailing Address - Country:US
Mailing Address - Phone:320-669-7564
Mailing Address - Fax:320-669-6003
Practice Address - Street 1:1025 10TH AVE
Practice Address - Street 2:
Practice Address - City:CLARKFIELD
Practice Address - State:MN
Practice Address - Zip Code:56223-1301
Practice Address - Country:US
Practice Address - Phone:320-669-7564
Practice Address - Fax:320-669-7564
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY10141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY112512500Medicaid