Provider Demographics
NPI:1831309566
Name:RENNER, JOSEPH A (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:A
Last Name:RENNER
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 1:11 PARK PL
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-2925
Mailing Address - Country:US
Mailing Address - Phone:618-233-7300
Mailing Address - Fax:618-233-7432
Practice Address - Street 1:11 PARK PL
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2925
Practice Address - Country:US
Practice Address - Phone:618-233-7300
Practice Address - Fax:618-233-7432
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics