Provider Demographics
NPI:1073783163
Name:WONENBERG, BRETT MICHAEL (DDS)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:MICHAEL
Last Name:WONENBERG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:FORTUNA
Mailing Address - State:CA
Mailing Address - Zip Code:95540-2451
Mailing Address - Country:US
Mailing Address - Phone:707-725-1303
Mailing Address - Fax:707-725-1358
Practice Address - Street 1:1730 MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-2451
Practice Address - Country:US
Practice Address - Phone:707-725-1303
Practice Address - Fax:707-725-1358
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA497061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice