Basic Information
| Provider Information | |||||||||
| NPI: | 1538255385 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1025 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | CLARKFIELD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562231301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206697564 | ||||||||
| FaxNumber: | 3206696003 | ||||||||
| Practice Location | |||||||||
| Address1: | 1025 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | CLARKFIELD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562231301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206697564 | ||||||||
| FaxNumber: | 3206697564 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 1014 | WY | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 112512500 | 05 | WY | MEDICAID |