Healthcare Provider Details

I. General information

NPI: 1902116288
Provider Name (Legal Business Name): GREAT LAKES ORAL & MAXILLOFACIAL SURGERY, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2010
Last Update Date: 10/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 CREST VIEW DR STE 1
HUDSON WI
54016-9391
US

IV. Provider business mailing address

1200 CREST VIEW DR STE 1
HUDSON WI
54016-9391
US

V. Phone/Fax

Practice location:
  • Phone: 715-381-7070
  • Fax: 715-381-0383
Mailing address:
  • Phone: 715-381-7070
  • Fax: 715-381-0383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number4482
License Number StateWI

VIII. Authorized Official

Name: DR. RICHARD WILLIAM BRUNTON
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 651-351-1010