Healthcare Provider Details

I. General information

NPI: 1558017459
Provider Name (Legal Business Name): CM ROMENESKO DDS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 03/01/2022
Certification Date: 03/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 E EVERGREEN DR
APPLETON WI
54913
US

IV. Provider business mailing address

2510 E. EVERGREEN DRIVE
APPLETON WI
54913
US

V. Phone/Fax

Practice location:
  • Phone: 920-739-7848
  • Fax:
Mailing address:
  • Phone: 920-739-7848
  • Fax: 920-903-1004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KENDALL A BUTLER
Title or Position: BUSINESS MANAGER
Credential:
Phone: 920-739-7848