Provider Demographics
NPI:1760126270
Name:ENSLIN, BRENDA (LDH)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:ENSLIN
Suffix:
Gender:F
Credentials:LDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4060 S LAKE DR APT 4
Mailing Address - Street 2:
Mailing Address - City:ST FRANCIS
Mailing Address - State:WI
Mailing Address - Zip Code:53235-5256
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4060 S LAKE DR APT 4
Practice Address - Street 2:
Practice Address - City:ST FRANCIS
Practice Address - State:WI
Practice Address - Zip Code:53235-5256
Practice Address - Country:US
Practice Address - Phone:612-237-8531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1004086-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI124Q0000XMedicaid