Provider Demographics
NPI:1336365949
Name:DEAN R. HUSSONG, DDS, SC
Entity type:Organization
Organization Name:DEAN R. HUSSONG, DDS, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:HUSSONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-453-5321
Mailing Address - Street 1:10 BRADLEY FARM RD
Mailing Address - Street 2:
Mailing Address - City:TOMAHAWK
Mailing Address - State:WI
Mailing Address - Zip Code:54487-1563
Mailing Address - Country:US
Mailing Address - Phone:715-453-5321
Mailing Address - Fax:
Practice Address - Street 1:10 BRADLEY FARM RD
Practice Address - Street 2:
Practice Address - City:TOMAHAWK
Practice Address - State:WI
Practice Address - Zip Code:54487-1563
Practice Address - Country:US
Practice Address - Phone:715-453-5321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5002144-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38391200Medicaid