Basic Information
| Provider Information | |||||||||
| NPI: | 1306809546 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THAYER | ||||||||
| FirstName: | DENA | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1316 MERCY DR | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494441835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317399461 | ||||||||
| FaxNumber: | 2317338131 | ||||||||
| Practice Location | |||||||||
| Address1: | 1316 MERCY DR | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494441835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317399461 | ||||||||
| FaxNumber: | 2317338131 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0122X | O16252 | MI | Y | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 4638958 | 05 | MI | MEDICAID |