Healthcare Provider Details

I. General information

NPI: 1093789331
Provider Name (Legal Business Name): FREDRICK C AUSTERMANN D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 12/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6217 S PACKARD AVE
CUDAHY WI
53110-3096
US

IV. Provider business mailing address

6217 S PACKARD AVE
CUDAHY WI
53110-3096
US

V. Phone/Fax

Practice location:
  • Phone: 414-764-5550
  • Fax: 414-764-8175
Mailing address:
  • Phone: 414-764-5550
  • Fax: 414-764-8175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number5000496
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: