Provider Demographics
NPI:1558374686
Name:THEISEN, JOSEPH RAYMOND (DDS)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:RAYMOND
Last Name:THEISEN
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 1:1102 REGIS CT
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-4404
Mailing Address - Country:US
Mailing Address - Phone:715-834-2032
Mailing Address - Fax:715-552-1552
Practice Address - Street 1:1102 REGIS CT
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-4404
Practice Address - Country:US
Practice Address - Phone:715-834-2032
Practice Address - Fax:715-552-1552
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5000361-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33658100Medicaid