Healthcare Provider Details

I. General information

NPI: 1942523436
Provider Name (Legal Business Name): TANNLEGER AS ORAL AND MAXILLOFACIAL SURGERY SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2010
Last Update Date: 03/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2359 MURPHY WOODS RD
BELOIT WI
53511-2343
US

IV. Provider business mailing address

2359 MURPHY WOODS RD
BELOIT WI
53511-2343
US

V. Phone/Fax

Practice location:
  • Phone: 608-362-9391
  • Fax: 608-362-8020
Mailing address:
  • Phone: 608-362-9391
  • Fax: 608-362-8020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. RONALD L GUTTU
Title or Position: OWNER
Credential: DDS
Phone: 608-362-9391