Provider Demographics
NPI:1730300823
Name:BREMER, DEWAYNE MAURICE
Entity Type:Individual
Prefix:MR
First Name:DEWAYNE
Middle Name:MAURICE
Last Name:BREMER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DEWAYNE
Other - Middle Name:MAURICE
Other - Last Name:BREMER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LD
Mailing Address - Street 1:160 NE 6TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-3131
Mailing Address - Country:US
Mailing Address - Phone:541-265-8200
Mailing Address - Fax:541-265-3536
Practice Address - Street 1:160 NE 6TH ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-3131
Practice Address - Country:US
Practice Address - Phone:541-265-8200
Practice Address - Fax:541-265-3536
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0516733789122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist