1003092206 NPI number — ANITA WHALEN DDS

Table of content: ANITA WHALEN DDS (NPI 1003092206)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003092206 NPI number — ANITA WHALEN DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHALEN
Provider First Name:
ANITA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WHALEN
Provider Other First Name:
MARY
Provider Other Middle Name:
JEAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1003092206
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
620 SUMMIT AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CROOKSTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56716-2799
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-281-3441
Provider Business Mailing Address Fax Number:
218-281-6966

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
508 NORTH MINNESOTA STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARREN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56762-0093
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-281-3441
Provider Business Practice Location Address Fax Number:
218-281-6966
Provider Enumeration Date:
01/17/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  D8197 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 531018100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".