Healthcare Provider Details

I. General information

NPI: 1801054572
Provider Name (Legal Business Name): FREDERICK CHARLES GELHAUS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2008
Last Update Date: 05/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 W BROADWAY AVE
MEDFORD WI
54451-1311
US

IV. Provider business mailing address

1055 W BROADWAY AVE
MEDFORD WI
54451-1311
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3192
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: