Provider Demographics
NPI:1437721982
Name:WENNER, CHARLES BERNARD (DDS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:BERNARD
Last Name:WENNER
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 1:18394 GLENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:MN
Mailing Address - Zip Code:56368-8123
Mailing Address - Country:US
Mailing Address - Phone:320-333-1719
Mailing Address - Fax:
Practice Address - Street 1:250 FULLER ST S
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-1323
Practice Address - Country:US
Practice Address - Phone:952-445-6657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND146351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice