Healthcare Provider Details

I. General information

NPI: 1285649921
Provider Name (Legal Business Name): ORAL & MAXILLOFACIAL SURGERY CONSULTANTS OF WISCONSIN, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4811 S 76TH ST SUITE 304
GREENFIELD WI
53220-4364
US

IV. Provider business mailing address

4811 S 76TH ST SUITE 304
GREENFIELD WI
53220-4364
US

V. Phone/Fax

Practice location:
  • Phone: 414-281-3344
  • Fax: 414-281-1080
Mailing address:
  • Phone: 414-281-3344
  • Fax: 414-281-1080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2699
License Number StateWI

VIII. Authorized Official

Name: DR. RONALD HENRY NELLEN
Title or Position: PRESIDENT
Credential: DDS
Phone: 414-281-3344