1013277094 NPI number — DR. ALYSSA LYNN GULLICKSON D.D.S.

Table of content: DR. ALYSSA LYNN GULLICKSON D.D.S. (NPI 1013277094)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013277094 NPI number — DR. ALYSSA LYNN GULLICKSON D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GULLICKSON
Provider First Name:
ALYSSA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BROWN
Provider Other First Name:
ALYSSA
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1013277094
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23665 N LAKESHORE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLENWOOD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56334-9375
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-808-4126
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
308 BLATTNER DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
AVON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56310-4531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-356-7374
Provider Business Practice Location Address Fax Number:
320-356-9427
Provider Enumeration Date:
05/23/2012

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: 122300000X , with the licence number:  D13077 , 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)





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