Healthcare Provider Details

I. General information

NPI: 1891234498
Provider Name (Legal Business Name): LMG INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2017
Last Update Date: 02/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6211 DURAND AVE SUITE 202
MOUNT PLEASANT WI
53406-4956
US

IV. Provider business mailing address

2626 N 76TH ST SUITE 105
WAUWATOSA WI
53213-1137
US

V. Phone/Fax

Practice location:
  • Phone: 262-598-9901
  • Fax: 262-898-3951
Mailing address:
  • Phone: 414-476-9400
  • Fax: 414-755-4769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JAY L MACKMAN
Title or Position: OWNER-DIRECTOR
Credential: D.D.S.
Phone: 414-476-9400