Healthcare Provider Details

I. General information

NPI: 1740284306
Provider Name (Legal Business Name): STEPHEN REYNOLDS VAN ESS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1053 FOND DU LAC AVE
KEWASKUM WI
53040-9495
US

IV. Provider business mailing address

1053 FOND DU LAC AVE
KEWASKUM WI
53040-9495
US

V. Phone/Fax

Practice location:
  • Phone: 262-626-8444
  • Fax: 262-626-8260
Mailing address:
  • Phone: 262-626-8444
  • Fax: 262-626-8260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number02775
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: