Provider Demographics
NPI:1073821278
Name:BEHM, ANITA LYNN (RDH)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:LYNN
Last Name:BEHM
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:ANITA
Other - Middle Name:LYNN
Other - Last Name:WISNEFSKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:160 S MACY ST
Mailing Address - Street 2:HEALTH DEPARTMENT
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4241
Mailing Address - Country:US
Mailing Address - Phone:920-929-3085
Mailing Address - Fax:920-929-3102
Practice Address - Street 1:160 S MACY ST
Practice Address - Street 2:HEALTH DEPARTMENT
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4241
Practice Address - Country:US
Practice Address - Phone:920-929-3085
Practice Address - Fax:920-929-3102
Is Sole Proprietor?:No
Enumeration Date:2010-09-22
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5413-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38397700Medicaid