Healthcare Provider Details

I. General information

NPI: 1225153513
Provider Name (Legal Business Name): MARK CHRISTIAN BRIEMAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 BRIDGE ST
MAYVILLE WI
53050-1635
US

IV. Provider business mailing address

105 BRIDGE ST
MAYVILLE WI
53050-1635
US

V. Phone/Fax

Practice location:
  • Phone: 920-387-2640
  • Fax: 920-387-0240
Mailing address:
  • Phone: 920-387-2640
  • Fax: 920-387-0240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5001271
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: