1255841722 NPI number — CRAIG MATTHEW ROSENTHAL DDS

Table of content: CRAIG MATTHEW ROSENTHAL DDS (NPI 1255841722)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255841722 NPI number — CRAIG MATTHEW ROSENTHAL DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSENTHAL
Provider First Name:
CRAIG
Provider Middle Name:
MATTHEW
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

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:
1255841722
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
714 HIGH LAND AVE APT 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KEWASKUM
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53040-9179
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 W LINCOLN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUPUN
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53963-1949
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
929-324-6256
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/10/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  4558 , 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)

  • Identifier: NONE . This is a "NONE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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