Healthcare Provider Details

I. General information

NPI: 1588790489
Provider Name (Legal Business Name): LISA M HEKENBERGER RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1711 SHAWANO AVE
GREEN BAY WI
54303
US

IV. Provider business mailing address

2664 SHERRY LANE
GREEN BAY WI
54302
US

V. Phone/Fax

Practice location:
  • Phone: 920-494-9541
  • Fax: 920-494-2026
Mailing address:
  • Phone: 920-406-3998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number5714016
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: