Healthcare Provider Details

I. General information

NPI: 1245159003
Provider Name (Legal Business Name): BRYNN PETERSON RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 EVERGREEN CT STE B
APPLETON WI
54913-8903
US

IV. Provider business mailing address

413 N 17TH AVE
WAUSAU WI
54401-4226
US

V. Phone/Fax

Practice location:
  • Phone: 920-734-4649
  • Fax:
Mailing address:
  • Phone: 715-298-3983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number7001998
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: