Provider Demographics
NPI:1942358635
Name:FENNIG, DAMIAN O (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAMIAN
Middle Name:O
Last Name:FENNIG
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 1:5520 MEDICAL CIR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-1226
Mailing Address - Country:US
Mailing Address - Phone:608-274-5714
Mailing Address - Fax:608-274-0591
Practice Address - Street 1:5520 MEDICAL CIR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1226
Practice Address - Country:US
Practice Address - Phone:608-274-5714
Practice Address - Fax:608-274-0591
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50015641223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics