Healthcare Provider Details

I. General information

NPI: 1710890900
Provider Name (Legal Business Name): EMILY DRIESENGA EFDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 MEMORIAL DR
OCONTO WI
54153-2053
US

IV. Provider business mailing address

155 MEMORIAL DR
OCONTO WI
54153-2053
US

V. Phone/Fax

Practice location:
  • Phone: 920-516-7107
  • Fax: 920-516-1940
Mailing address:
  • Phone: 920-516-7107
  • Fax: 920-516-1940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number50149-116
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: