Provider Demographics
NPI:1588394118
Name:ANDERSON, NICOLE MARIE (DDS)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:MARIE
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 1:30400 71ST AVENUE WAY
Mailing Address - Street 2:
Mailing Address - City:CANNON FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:55009-4010
Mailing Address - Country:US
Mailing Address - Phone:507-291-4913
Mailing Address - Fax:
Practice Address - Street 1:411 MAIN ST W
Practice Address - Street 2:
Practice Address - City:CANNON FALLS
Practice Address - State:MN
Practice Address - Zip Code:55009-2074
Practice Address - Country:US
Practice Address - Phone:507-263-2411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-15
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14771122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist