Provider Demographics
NPI:1750587564
Name:PEDERSEN, SARAH J (RDH, CDHC)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:J
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:RDH, CDHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1811 MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-7900
Mailing Address - Country:US
Mailing Address - Phone:715-836-0127
Mailing Address - Fax:
Practice Address - Street 1:1811 MEADOW LN
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-7900
Practice Address - Country:US
Practice Address - Phone:715-836-0127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4176-016124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33806200Medicaid