Provider Demographics
NPI:1497815948
Name:BRENEMAN-WISONG, LYNN M (DDS)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:M
Last Name:BRENEMAN-WISONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:M
Other - Last Name:BRENEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:500 W RIVER DR
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52801-1014
Mailing Address - Country:US
Mailing Address - Phone:563-336-3000
Mailing Address - Fax:563-336-3229
Practice Address - Street 1:125 SCOTT ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52801-1130
Practice Address - Country:US
Practice Address - Phone:563-336-3221
Practice Address - Fax:563-336-3229
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA083991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA08399OtherPRIVATE INSURANCES
IA0080200Medicaid
IA1875119OtherUNITED CONCORDIA
IA08399OtherIA DELTA DENTAL
IL9183715Medicaid
IA22006OtherIA BLUE DENTAL