MEDICARE: ERIC P TESCH D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	4719	WI

General Provider Information

NPI Number	:	1457484552
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIC P TESCH D.D.S.

Provider Business Mailing Address
First Line	:	1409 CRYSTAL LAKE DR
Second Line	:
City	:	OCONOMOWOC
State	:	WI
Zip	:	53066-1769
Country	:	US
Telephone Number	:	262-569-8980
Fax Number	:

Provider Business Practice Location Address
First Line	:	7906 N 76TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53223-3916
Country	:	US
Telephone Number	:	414-354-9020
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2007
Last Update Date	:	07/08/2007

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