Provider Demographics
NPI:1336397900
Name:TOBERMAN, DEVAN MICHELLE (RDH)
Entity type:Individual
Prefix:
First Name:DEVAN
Middle Name:MICHELLE
Last Name:TOBERMAN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 E BLUFF ST
Mailing Address - Street 2:
Mailing Address - City:BOSCOBEL
Mailing Address - State:WI
Mailing Address - Zip Code:53805-1610
Mailing Address - Country:US
Mailing Address - Phone:608-326-8210
Mailing Address - Fax:
Practice Address - Street 1:109 E BLUFF ST
Practice Address - Street 2:
Practice Address - City:BOSCOBEL
Practice Address - State:WI
Practice Address - Zip Code:53805-1610
Practice Address - Country:US
Practice Address - Phone:608-326-8210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-08
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI124Q00000X124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33828700Medicaid