Provider Demographics
NPI:1104972033
Name:THIELEN, BRIAN M (DMD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:M
Last Name:THIELEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1543 PARK PL
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-1970
Mailing Address - Country:US
Mailing Address - Phone:920-405-3600
Mailing Address - Fax:920-405-9057
Practice Address - Street 1:1543 PARK PL
Practice Address - Street 2:SUITE 300
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-1970
Practice Address - Country:US
Practice Address - Phone:920-405-3600
Practice Address - Fax:920-405-9057
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice