Healthcare Provider Details

I. General information

NPI: 1275667149
Provider Name (Legal Business Name): ORTHODONTIC SPECIALISTS OF MADISON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 S GAMMON RD STE. 150
MADISON WI
53717-1400
US

IV. Provider business mailing address

202 S GAMMON RD STE. 150
MADISON WI
53717-1400
US

V. Phone/Fax

Practice location:
  • Phone: 608-664-9500
  • Fax: 608-664-9566
Mailing address:
  • Phone: 608-664-9500
  • Fax: 608-664-9566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3613-015
License Number StateWI

VIII. Authorized Official

Name: DR. STEVEN D. PETERSON
Title or Position: PRESIDENT
Credential: D.D.S.,M.S.
Phone: 608-664-9500