Provider Demographics
NPI:1720028624
Name:WENNER, JOSEPH HALL (DDS)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:HALL
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 1:1900 CENTRACARE CIRCLE
Mailing Address - Street 2:STE 0350
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-5000
Mailing Address - Country:US
Mailing Address - Phone:320-253-0272
Mailing Address - Fax:320-251-2661
Practice Address - Street 1:1900 CENTRACARE CIRCLE
Practice Address - Street 2:STE 0350
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-5000
Practice Address - Country:US
Practice Address - Phone:320-253-0272
Practice Address - Fax:320-251-2661
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN77651223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP18378OtherHEALTH PARTNERS
MN3B445WEOtherBLUE CROSS BLUE SHIELD
MN941218200Medicaid