Provider Demographics
NPI:1184712838
Name:WICHMANN, JEFFREY KENT (DDS)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:KENT
Last Name:WICHMANN
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 1:14600 GRANADA DR
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-7419
Mailing Address - Country:US
Mailing Address - Phone:952-432-8110
Mailing Address - Fax:952-432-4457
Practice Address - Street 1:7373 147TH ST. W. #116
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124
Practice Address - Country:US
Practice Address - Phone:952-432-8110
Practice Address - Fax:952-432-4457
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND120691223G0001X
MN120691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice