Provider Demographics
NPI:1457589491
Name:ABRAHAM, REENA (DMD)
Entity Type:Individual
Prefix:
First Name:REENA
Middle Name:
Last Name:ABRAHAM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:REENA
Other - Middle Name:
Other - Last Name:MATHEWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:2416 N PEACH AVE
Mailing Address - Street 2:APT 3
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-8355
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2416 N PEACH AVE
Practice Address - Street 2:APT 3
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-8355
Practice Address - Country:US
Practice Address - Phone:715-254-1094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS037906122300000X
WI65801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist