Healthcare Provider Details

I. General information

NPI: 1144772906
Provider Name (Legal Business Name): ORAL FACIAL AND PERIODONTAL SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2016
Last Update Date: 07/21/2025
Certification Date: 07/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13200 GLOBE DR STE 108
MT PLEASANT WI
53177-1606
US

IV. Provider business mailing address

13200 GLOBE DR STE 108
MT PLEASANT WI
53177-1606
US

V. Phone/Fax

Practice location:
  • Phone: 262-886-0147
  • Fax:
Mailing address:
  • Phone: 262-886-0147
  • Fax: 262-886-0570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MARY BALLARD
Title or Position: OWNER
Credential: DDS
Phone: 262-886-0147