Provider Demographics
NPI:1376980300
Name:DUFRESNE, ALINE (DMD)
Entity type:Individual
Prefix:
First Name:ALINE
Middle Name:
Last Name:DUFRESNE
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 1:1635 N WATER ST
Mailing Address - Street 2:APT 507
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-2793
Mailing Address - Country:US
Mailing Address - Phone:410-491-4454
Mailing Address - Fax:
Practice Address - Street 1:10155 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:STURTEVANT
Practice Address - State:WI
Practice Address - Zip Code:53177-1645
Practice Address - Country:US
Practice Address - Phone:262-664-7743
Practice Address - Fax:262-664-7799
Is Sole Proprietor?:No
Enumeration Date:2013-05-31
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001422-151223P0221X
MD157241223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD097733100Medicaid