Provider Demographics
NPI:1912015934
Name:DEJEAN, YVONNE R (DMD)
Entity Type:Individual
Prefix:
First Name:YVONNE
Middle Name:R
Last Name:DEJEAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-2614
Mailing Address - Country:US
Mailing Address - Phone:715-387-1896
Mailing Address - Fax:
Practice Address - Street 1:806 W 5TH ST
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-2614
Practice Address - Country:US
Practice Address - Phone:715-387-1896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29261223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33475400Medicaid
WI000177750Medicare ID - Type Unspecified
T95300Medicare UPIN