Provider Demographics
NPI:1790962231
Name:ROMENESKO, BRADLEY M (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:M
Last Name:ROMENESKO
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 1:3915 HALL AVE
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-1017
Mailing Address - Country:US
Mailing Address - Phone:715-735-3897
Mailing Address - Fax:715-735-3897
Practice Address - Street 1:3915 HALL AVE
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-1017
Practice Address - Country:US
Practice Address - Phone:715-735-3897
Practice Address - Fax:715-735-3897
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-28
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI34311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice