=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043341993
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRAIG B THIESSEN D.D.S., M.S.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2007
-----------------------------------------------------
Last Update Date | 08/16/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 311 FINANCIAL WAY SUITE 240
-----------------------------------------------------
City | WAUSAU
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54401-4288
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-298-9271
-----------------------------------------------------
Fax | 715-298-9272
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 311 FINANCIAL WAY SUITE 240
-----------------------------------------------------
City | WAUSAU
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54401-4288
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-298-9271
-----------------------------------------------------
Fax | 715-298-9272
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 5856
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------