1497815948 NPI number — LYNN M BRENEMAN-WISONG DDS

Table of content: LYNN M BRENEMAN-WISONG DDS (NPI 1497815948)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497815948 NPI number — LYNN M BRENEMAN-WISONG DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRENEMAN-WISONG
Provider First Name:
LYNN
Provider Middle Name:
M
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:
BRENEMAN
Provider Other First Name:
LYNN
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DDS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1497815948
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 W RIVER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAVENPORT
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52801-1014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-336-3000
Provider Business Mailing Address Fax Number:
563-336-3229

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
125 SCOTT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAVENPORT
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52801-1130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-336-3221
Provider Business Practice Location Address Fax Number:
563-336-3229
Provider Enumeration Date:
12/12/2006

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:  08399 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 08399 . This is a "PRIVATE INSURANCES" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0080200 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1875119 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 08399 . This is a "IA DELTA DENTAL" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 9183715 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 22006 . This is a "IA BLUE DENTAL" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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