Mason P Wistenberg

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

1002699-15 Issued in WI

Practice address

3071 Voyager Dr Ste B
Green Bay, WI 54311-8352

Phone

(920) 465-9887

NPI assigned

Feb 24, 2021

Last updated

Aug 15, 2022By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Voyager Family Dental LLC

  • General Practice Dentistry
  • Green Bay, WI
  • NPI 1528849114
  NPD Authorized official
• Voyager Drive Dental, SC

  • Dentist
  • Green Bay, WI
  • NPI 1124151741
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1614124800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1660521600000",
    "number": "1780278283",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "481 SAINT MARYS BLVD",
            "city": "GREEN BAY",
            "state": "WI",
            "postal_code": "543012607"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3071 VOYAGER DR STE B",
            "city": "GREEN BAY",
            "state": "WI",
            "postal_code": "543118352",
            "telephone_number": "920-465-9887"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WISTENBERG",
        "first_name": "MASON",
        "middle_name": "P",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2021-02-24",
        "last_updated": "2022-08-15",
        "certification_date": "2022-08-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "WI",
            "license": "1002699-15",
            "primary": true
        },
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Wisconsin Vein Institute
• Wisconsin Vision, LLC
• John David Wise, PA
• Sara Noel Wisneski
• Alexa Rose Wistenberg, OT
• Danielle R Witbro, NDTR, CWP
• Thomas Jens Witek, DDS
• Mary T Withee, RD, CDE
• Jane K Witman, MD
• William T Witmer, MD

• General Practice Dentistry in Green Bay, WI
• Providers in Green Bay, WI by specialty
• General Practice Dentistry in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 15, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.