Provider Demographics
NPI:1699420299
Name:BREESE, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BREESE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 E COMMERCE CT
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:WI
Mailing Address - Zip Code:53121-4360
Mailing Address - Country:US
Mailing Address - Phone:262-686-1388
Mailing Address - Fax:
Practice Address - Street 1:205 E COMMERCE CT
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-4360
Practice Address - Country:US
Practice Address - Phone:262-686-1388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-14
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4668124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist