Provider Demographics
NPI:1629568779
Name:THEISEN, JULIE
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:THEISEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15954 RIVERS EDGE DR STE 304
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-7894
Mailing Address - Country:US
Mailing Address - Phone:715-634-2541
Mailing Address - Fax:715-934-5554
Practice Address - Street 1:15954 RIVERS EDGE DR
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-7800
Practice Address - Country:US
Practice Address - Phone:715-634-2541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist