Healthcare Provider Details

I. General information

NPI: 1326573320
Provider Name (Legal Business Name): GELHAUS DENTAL CLINIC S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2017
Last Update Date: 04/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 W BROADWAY AVE
MEDFORD WI
54451-1372
US

IV. Provider business mailing address

1155 W BROADWAY AVE
MEDFORD WI
54451-1372
US

V. Phone/Fax

Practice location:
  • Phone: 715-748-4020
  • Fax: 715-748-4020
Mailing address:
  • Phone: 715-748-4020
  • Fax: 715-748-4020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number6784
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number7139
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3192
License Number StateWI

VIII. Authorized Official

Name: DR. FREDERICK CHARLES GELHAUS
Title or Position: DENTIST
Credential: DDS
Phone: 715-748-4020