1205136074 NPI number — GREAT LAKES ORAL & MAXILLOFACIAL SURGERY, P.A.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205136074 NPI number — GREAT LAKES ORAL & MAXILLOFACIAL SURGERY, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREAT LAKES ORAL & MAXILLOFACIAL SURGERY, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205136074
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
227 MERIDIAN DR # 6
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW RICHMOND
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54017-2565
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-246-5150
Provider Business Mailing Address Fax Number:
715-246-5102

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
227 MERIDIAN DR # 6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW RICHMOND
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54017-2565
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-246-5150
Provider Business Practice Location Address Fax Number:
715-246-5102
Provider Enumeration Date:
10/27/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
CONNIE
Authorized Official Middle Name:
LOUISE
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
651-351-1010

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  4482 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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