Healthcare Provider Details

I. General information

NPI: 1134455439
Provider Name (Legal Business Name): JAY PATRICH BRENDEMUEHL RDH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2009
Last Update Date: 10/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 EASTPARK BLVD
MADISON WI
53718-2149
US

IV. Provider business mailing address

5100 EASTPARK BLVD
MADISON WI
53718-2149
US

V. Phone/Fax

Practice location:
  • Phone: 608-222-8232
  • Fax:
Mailing address:
  • Phone: 608-222-8232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number5204
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: