Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 5810-015 | WI |
NPI | 1003929266 |
---|---|
Provider Name | Jane Lynn Reyerson |
First Address | Kenosha, WI 53142-1450 |
Second Address | Kenosha, WI 53142-1450 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
33792700 | (05) | WI |