Provider Demographics
NPI:1932632353
Name:WANEZEK, JACQUELINE (DDS)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:WANEZEK
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 1:2365 DONARSKI CT
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54302-4329
Mailing Address - Country:US
Mailing Address - Phone:920-621-7465
Mailing Address - Fax:
Practice Address - Street 1:2365 DONARSKI CT
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54302-4329
Practice Address - Country:US
Practice Address - Phone:920-621-7465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-04
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program