Provider Demographics
NPI:1558508069
Name:BRECKE, STEPHANIE (RDH BS MS)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:
Last Name:BRECKE
Suffix:
Gender:F
Credentials:RDH BS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 N 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4226
Mailing Address - Country:US
Mailing Address - Phone:715-842-4649
Mailing Address - Fax:
Practice Address - Street 1:413 N 17TH AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4226
Practice Address - Country:US
Practice Address - Phone:715-842-4649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-21
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3628-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist