Provider Demographics
NPI:1487700571
Name:WEGNER, KORY K
Entity type:Individual
Prefix:
First Name:KORY
Middle Name:K
Last Name:WEGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1803 E JUNIPER WAY
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029-8672
Mailing Address - Country:US
Mailing Address - Phone:262-367-7441
Mailing Address - Fax:414-964-0682
Practice Address - Street 1:105 E SILVER SPRING DR
Practice Address - Street 2:
Practice Address - City:WHITEFISH BAY
Practice Address - State:WI
Practice Address - Zip Code:53217-4702
Practice Address - Country:US
Practice Address - Phone:414-964-0680
Practice Address - Fax:414-964-0682
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
WI4301WI1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice