Healthcare Provider Details

I. General information

NPI: 1760894729
Provider Name (Legal Business Name): ERIC BIEDERWOLF D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2014
Last Update Date: 06/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18900 W BLUEMOUND RD SUITE 218
BROOKFIELD WI
53045-6092
US

IV. Provider business mailing address

18900 W BLUEMOUND RD SUITE 218
BROOKFIELD WI
53045-6092
US

V. Phone/Fax

Practice location:
  • Phone: 262-754-2727
  • Fax:
Mailing address:
  • Phone: 262-754-2727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7262-15
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: