Provider Demographics
NPI:1861559148
Name:PEERENBOOM, JAY FRANCIS (DDS)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:FRANCIS
Last Name:PEERENBOOM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CORPORATE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-1722
Mailing Address - Country:US
Mailing Address - Phone:715-842-9968
Mailing Address - Fax:715-842-9478
Practice Address - Street 1:1 CORPORATE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-1722
Practice Address - Country:US
Practice Address - Phone:715-842-9968
Practice Address - Fax:715-842-9478
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001905-015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist