=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912015934
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | YVONNE R. DEJEAN DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2006
-----------------------------------------------------
Last Update Date | 09/14/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 806 W 5TH ST
-----------------------------------------------------
City | MARSHFIELD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54449-2614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-387-1896
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 806 W 5TH ST
-----------------------------------------------------
City | MARSHFIELD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54449-2614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-387-1896
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 2926
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 204E00000X
-----------------------------------------------------
Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
-----------------------------------------------------
License Number | 2926
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------