Healthcare Provider Details

I. General information

NPI: 1528241486
Provider Name (Legal Business Name): ASSOCIATED ORAL & MAXILLOFACIAL SURGEONS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2007
Last Update Date: 06/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N89 W16785 APPLETON AVE
MENOMONEE FALLS WI
53051
US

IV. Provider business mailing address

N89 W16785 APPLETON AVE
MENOMONEE FALLS WI
53051
US

V. Phone/Fax

Practice location:
  • Phone: 262-253-6588
  • Fax: 262-253-6893
Mailing address:
  • Phone: 262-253-6588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4287
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number4287
License Number StateWI

VIII. Authorized Official

Name: DR. TERRENCE JOHN RIESCH
Title or Position: PRESIDENT
Credential: DDS
Phone: 262-253-6588