Provider Demographics
NPI:1487879243
Name:HEDSTROM, ALYSSA ANNE (DDS)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:ANNE
Last Name:HEDSTROM
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:PO BOX 670
Mailing Address - Street 2:
Mailing Address - City:GRAND MARAIS
Mailing Address - State:MN
Mailing Address - Zip Code:55604-0670
Mailing Address - Country:US
Mailing Address - Phone:218-387-2774
Mailing Address - Fax:218-387-1393
Practice Address - Street 1:303 E 3RD STREET
Practice Address - Street 2:
Practice Address - City:GRAND MARAIS
Practice Address - State:MN
Practice Address - Zip Code:55604
Practice Address - Country:US
Practice Address - Phone:218-387-2774
Practice Address - Fax:218-387-1393
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND119421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice