Healthcare Provider Details

I. General information

NPI: 1275973166
Provider Name (Legal Business Name): MERIDIAN ENDODONTICS AND PERIODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 06/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20350 WATER TOWER BLVD STE 203
BROOKFIELD WI
53045-3558
US

IV. Provider business mailing address

20350 WATER TOWER BLVD STE 203
BROOKFIELD WI
53045-3558
US

V. Phone/Fax

Practice location:
  • Phone: 262-327-6100
  • Fax:
Mailing address:
  • Phone: 262-327-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number6591
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number6852.15
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number6841.15
License Number StateWI

VIII. Authorized Official

Name: DR. JARED FRISBIE-TEEL
Title or Position: OWNER/DOCTOR
Credential:
Phone: 262-327-6100