Healthcare Provider Details

I. General information

NPI: 1003201112
Provider Name (Legal Business Name): JASON MEINHARDT DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2015
Last Update Date: 08/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2115 S MEMORIAL PL
SHEBOYGAN WI
53081
US

IV. Provider business mailing address

2115 S MEMORIAL PL
SHEBOYGAN WI
53081-3714
US

V. Phone/Fax

Practice location:
  • Phone: 920-458-7781
  • Fax: 920-458-2015
Mailing address:
  • Phone: 920-458-7781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number1001453-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: