Provider Demographics
NPI:1689171282
Name:NEISEN, TRENT JOHN (DDS)
Entity Type:Individual
Prefix:
First Name:TRENT
Middle Name:JOHN
Last Name:NEISEN
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 1:1016 1ST ST S
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-3510
Mailing Address - Country:US
Mailing Address - Phone:320-235-2010
Mailing Address - Fax:
Practice Address - Street 1:1016 1ST ST S
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-3510
Practice Address - Country:US
Practice Address - Phone:320-235-2010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-10
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND140131223G0001X
AZ10295122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist