Provider Demographics
NPI:1003929266
Name:REYERSON, JANE LYNN (DDS)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:LYNN
Last Name:REYERSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7117 GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-1450
Mailing Address - Country:US
Mailing Address - Phone:262-942-7000
Mailing Address - Fax:262-942-7117
Practice Address - Street 1:7117 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-1450
Practice Address - Country:US
Practice Address - Phone:262-942-7000
Practice Address - Fax:262-942-7117
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5810-0151223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33792700Medicaid