Provider Demographics
NPI:1720570419
Name:WENGER, ALYSE (DDS)
Entity Type:Individual
Prefix:
First Name:ALYSE
Middle Name:
Last Name:WENGER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6488 NE 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:IA
Mailing Address - Zip Code:50327-8827
Mailing Address - Country:US
Mailing Address - Phone:262-945-1250
Mailing Address - Fax:
Practice Address - Street 1:1210 NW 18TH ST
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023
Practice Address - Country:US
Practice Address - Phone:515-964-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-30
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADDS-095481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice